Category Archives: Study Days

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 …


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 …



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)


Stop 3: Philadelphia

ACOGfilmOnto the City of Brotherly (and Sisterly) Love …

The original plan was to provide one Philadelphia-based study day while I was in town for the 20-year reunion of the Kelly Writers House, and the showing of our film on ‘Upright breech birth’ at the ACOG Annual Meeting. If being-with-breech teaches you anything, it is to go with the flow, as things rarely unfold as expected. The two main events conflicted, and the original study day was fully booked within a week or two of the listing. The demand for breech training spread quickly north and south, from Montreal to Atlanta. Clearly, many in North America are keen to develop skills and change the current breech culture.

Finally, the obstetricians join us! (They are always invited.) I was so pleased that three board-certified obstetricians attended this training. This is a big deal in Philly, one of the largest cities in America, where the midwives were unable to identify a single hospital-based practice where they can refer women who want to explore a vaginal breech birth. Big journeys begin with small steps.

bcflags2Although I have been reassured that every evaluation of this training indicates those attending increase their confidence in supine/lithotomy breech delivery as well as upright techniques, I sometimes worry that our physiological birth-based approach might alienate doctors who work in settings where 90% of women have epidurals in labour. But I guess midwives who work in out-of-hospital settings have felt the same way for years, as their training has been determined by obstetricians whose challenges and location-specific resources are very different. We had great discussions, and there feels a real potential for future collaborative working in this area. (And of course I am wondering if the law of ‘attracting breeches‘ will take effect … ) 😉

Lifecycle WomanCare

Lifecycle WomanCare

The Philadelphia training was hosted by Lifecycle WomanCare, and organised by their Clinical Director, CNM Julie Cristol, who also has a passion for helping others to develop their physiological birth skills for normal birth. Thank you, Julie! Their practice is located in a beautiful building, right next to the original Bryn Mawr Birth Centre. I was so pleased to be able to have a brief tour of their home.

In Philly, we had a 3-hour half-day event because that is what fit everyone’s schedules this time around. Unfortunately, my old friend Christy Santoro was unable to attend because she was at a birth! See you next time, Christy. I enjoyed making new acquaintances and hope to see the Lifecycle crowd again. Didn’t get time to take many pictures because we spent our limited time together talking breech and research, then Dad and I departed for our 9-hour drive to Asheville! Epic …

Tomorrow: We arrive in Asheville to teach breech in the Blue Ridge Mountains of North Carolina …


Second stop: Tillsonburg, Ontario

Celebrating Norfolk Roots Midwifery!

Celebrating Norfolk Roots Midwifery!

From Montreal, it was on to Tillsonburg, Ontario, ‘near Toronto’ — because in Canadian terms, within 3 hours is ‘near.’ The places around Tillsonburg are confusingly called things like London, Norwich, and Cambridge. The lovely Norfolk Roots Midwifery team gave me one of their bags to remember my visit. Can’t wait to take it back to Norfolk, England with me!


Midwife Joanna Nemrava came from British Columbia to share breech skills!

Midwife Joanna Nemrava came from British Columbia to share breech skills!

Again, the training was attended by midwives who came from various places throughout Canada and the US, including Alberta, British Columbia and Michigan, south of the border. I was privileged to meet Stacia Proefrock, a breech-experienced midwife from south-central Michigan. In addition to attending breech births, Stacia has experience teaching others about physiological breech birth and is the current president of the Michigan Midwives Association – a great person to be in touch with if you would like to organise a study day of your own in this area.


Teaching in Tillsonburg; photo: Sheila Stubbs

Teaching in Tillsonburg; photo: Sheila Stubbs

While in Ontario, I picked up a Deverra birth stool for use in teaching and births. The stool is visible in the photo to the right. I love their design, which features a wooden seat and 360º visibility. The Deverra birth stool is also completely portable; the legs unscrew and it comes in its own carry bag. When professionals are making the transition to active breech birth but can’t quite wrap their heads around facilitating a breech birth from behind the woman, I often recommend a birth stool as a good compromise — the woman remains mobile and upright, while the baby emerges facing a direction familiar to the attendant. While other birth stools are available, I am quite happy with this one, another reminder of my trip to Ontario!

At the end of each study day, we spend some time discussing how professionals acquire breech experience when breech births are not very common, including the concept of ‘attracting breeches,’ emerging in my current research. I know several of those attending this study day have sharpened their skills, reflected on the experiences they have already had, and are open to attracting breeches, so I look forward to seeing what happens among this group. Of course, in Ontario, activists have a great model in the Ottawa-based Coalition for Breech Birth and Midwife Dr Betty-Anne Daviss, who have worked together to enable midwife-facilitated breech births in hospitals in that area. Join forces with each other and work together for change!


practising breech manoeuvres

The training was held in the house of author, speaker and birth activist Sheila Stubbs, who holds regular Birth Nerd gatherings in her home. The warmth and sisterhood in this community was very strong, and Sheila reminded me of Norwich’s beloved doula mother, Rachel Graveling. Thankfully, Sheila gave me a signed copy of her book for the Norwich Birth Group lending library.

Thanks also to Christine McGillis, who organised this training in Tillsonburg. ❤️

Tomorrow: On to Philadelphia, and the start of my Father-Daughter road trip!


a walk around beautiful Tillsonburg

a walk around beautiful Tillsonburg

First stop: Montreal

Earlier this month (May 2016), I completed a road trip from Montreal to Atlanta to share the results of our international consensus research (Walker et al 2016), explain how it can be used to guide practice and education, and deliver physiological breech birth training based on that research to approximately 130 health professionals and other birth workers.

Wall mural depicting the Maison de naissance, Côte-des-Neiges

Wall mural depicting the Maison de naissance, Côte-des-Neiges

The goal was to enable these professionals to learn new skills, equip them to continue learning using an on-line Virtual Community of Practice, and empower them to disseminate the knowledge to others in their local communities. I met so many wonderful people, and feel confident they will work to extend the availability of skilled support for planned vaginal birth. I am going to tell the story of this amazing road trip in a blog mini-series. I hope you will join us … there is a special surprise at the end! 😉

The first workshop was attended by Certified Midwives from Quebec, Ontario, Maine, and Massachusetts, as well as doulas and CPMs from these communities. In Quebec, midwives work mostly in community settings and are not legally able to attend breech births except in emergencies (undiagnosed). However, some of the midwives have begun to work with obstetricians who will accept planned breech births, and they are working towards woman-centred, physiological care for these women. They also want to ensure emergency skills training is up-to-date, including physiologically-based strategies appropriate to midwifery-led settings.

Certified Midwives Sinclair Harris, Mounia Amine, Sylvie Carignan, and Sylvie Saunier

Certified Midwives Sinclair Harris, Mounia Amine, Sylvie Carignan, and Sylvie Saunier

As physiological breech birth gradually becomes the standard of practice, especially for midwives, breech skills will increasingly be taught by trainers who may or may not have much breech clinical experience themselves, much like they are now. It is therefore important that trainers be able to become ‘qualified’ to teach physiological breech methods, in the same way they teach supine-based emergency delivery techniques, and that they are teaching methods underpinned by research and consensus. Several skills trainers from throughout Quebec attended the workshop, and by using the resources made available, hope to disseminate the training to others in their local communities. I especially enjoyed meeting Sinclair Harris, the grandmother of this midwifery community, who has nurtured so many young midwives and is still actively teaching. Sinclair completed her RN training at St Mary’s in London. ❤️

Anyone in Quebec interested in receiving training

in the facilitation of physiological breech births —

 contact Andrea Houle, the RSFQ Agente de Formation.

(contact form below)

Certified Midwife Bronwen Agnew

Certified Midwife Bronwen Agnew

The midwives told me that use of ‘prayer hands’ in rotational manoeuvres to release the arms struck a chord with them. The shoulder press manoeuvre also made sense, but some midwives felt that the two disctint versions of this manoeuvre needed independent descriptive terms, to capture subtly different techniques which are applicable in various circumstances. This cluster of manoeuvres have been taught as “Frank’s Nudge,” in honour of Frankfurt obstetrician Professor Frank Louwen. But because research indicates eponyms (named after people rather than descriptive terms) can lead to confusion and inadequate documentation, we try to use a description which ‘does what it says on the tin’ in the Breech Birth Network training, and we continually listen to feedback about what works to help novices learn breech better. More on the distinction between these manoeuvres coming up in a future blog …

CPM and doula Rivka Cymbalist with the world's youngest breech catcher

CPM and doula Rivka Cymbalist with the world’s youngest breech catcher

Following the workshop, midwife Bronwen Agnew was kind enough to take me on a tour of the Maison de naissance, Côte-des-Neiges. This local birth centre is housed in a wonderful old rectory building, complete with wooden floors. It reminded me of my grandmother’s house, warm and simple. A beautiful place to give birth! Thank you, Bronwen.

The Montreal workshop was organised by Montreal doula and CPM, Rivka Cymbalist, and held at Studio L’équilibre en mouvement, ave Van Horne, a wonderful venue. We also enjoyed lunch at Rivka’s cafe, Caffe della Pace. Thank you, Rivka and family for your hospitality! If you are ever in Montreal, I also recommend relaxing at La Société Textile, a crafts shop / café where you pay by the hour to hang out, work on your knitting/sewing project, and drink unlimited tea from the kitchen. What more could a midwife ask for?

The current plan is to provide a 2-day breech train-the-trainers course in Toronto in late July / early August 2017, involving myself and some of the midwives who have taken the training this year and will be disseminating the skills in their communities. This is due to abundant feedback from the participants that they would like the training to be longer to allow for more discussion, reflection, fellowship and hands-on practice — of course we support all of the above! Follow this blog or the Breech Birth Network Facebook page to keep updated on our plans.

Tomorrow: Join us as we travel to Tillsonburg, Ontario!


Evaluating breech training in North America

ShawnPortsmouthBusy packing … leaving London for the US on Friday. Originally, I planned to attend the celebration of 20 Years of the Kelly Writers House and my college reunion at Penn, as well as the annual ACOG meeting where our film on upright breech birth is being shown, followed by a family wedding. But it turns out the first two conflicted, so instead I will be spending half of my holiday teaching breech in collaboration with other health professionals along the east coast of the US and Canada. With ‘renewed interest’ in vaginal breech birth from the ACOG, and Canadian SOGC guidelines fully supporting planned breech birth since 2009, the will to revive breech skills is in full swing in North America!

Some of the health professionals and birth activists collaborating to provide breech training in their communities include:

  • Atlanta, Georgia – See Baby Midwifery is dedicated to providing options and support to women and families in the 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). The SeeBaby Team will lead a panel discussion on ways forward in the support of vaginal breech birth, and Dr Brad Bootstaylor is collaborating on the analysis of the evaluation data from this series of training days. (Places available.)
  • Asheville, North Carolina – This is a community which values co-operation, and the study days here have been organised collaboratively by obstetricians, CNMs, CPMs and doulas. Dr David Hayes of Harvest Moon Women’s Health is also contributing to the analysis of the evaluation data. Thanks especially to Kathleen Davies and Jennifer White.
  • Philadelphia, Pennsylvania – Thank you to Julie Cristol, CNM, of Lifecycle WomanCare for enabling this workshop.
  • Tillsonburg, Ontario – Thank you to Christine McGillis and Sheila Stubbs for making this workshop happen in Ontario.
  • Montreal, Quebec – Thank you to Rivka Cymbalist for organising this workshop and raising awareness of the need to increase vaginal breech birth options in this community. (Places available.)

The training provided by Breech Birth Network is different from obstetric emergencies training because it is based on physiological birth principles, including the importance of maternal movement in facilitating the birth process. Decisions on when or whether to intervene in a breech birth are determined by careful observation of the unfolding mechanisms, recognition of deviations from the norm and strategies to restore the mechanism. These strategies include maternal movements, as well as hands-on help from birth professionals. In Breech Birth Network training, which follows recommendations outlined in primary research with experienced professionals, birth videos are central resources, enabling both experienced and inexperienced professionals to develop and expand their pattern recognition skills, even in communities where actual breech births remain a rarity. Therefore, the training is supplemented by secure access to the resources and videos, which cannot be downloaded, but can be used to refresh training by those who attend the hands-on workshops when preparing for a birth within their local teams — the Virtual Community of Practice (VCOP).

Thank you to the women, midwives and obstetricians who have made this possible in order to increase the safety of breech birth for others.

Training programmes are often evaluated according to Kirkpatrick’s hierarchy, which has 4 levels:

Thorough evaluations of breech birth training packages are lacking. Evaluating impact of training on maternal/neonatal outcomes is a longer-term project, easier to achieve when considering the effect of training within one site, rather than professionals working in many different contexts; we have plans to begin such a project later in the year. However, for this series of study days in North America, we are collecting data on how many breech births those participating have attended in the year before and after training (change in behaviour), as well as changes in confidence levels before and after training (change in learning).

networklearningThose attending these training days include obstetricians, CNMs, CPMs, students, and birth activists keen to support cultural change in their communities. The results of the evaluation will help us to determine whether providing breech birth training based on conceptual understanding of physiological principles, within a community of practice/network learning model, will increase women’s access to the option of vaginal breech birth by increasing provider confidence and skills to provide this service.

The evaluation data will also contribute to answering two fundamental questions, which will require on-going research in the future:

  1. How can vaginal breech birth skills be revived within communities which have few or no experienced providers?
  2. How does training based on physiological principles impact the safety of breech birth for mothers and neonates?

Thank you to all the health professionals participating in this training and evaluation. I am looking forward to meeting you and learning from your communities!


P.S. Of course, we aren’t the only source of physiological breech birth training. Others include:

We advocate that all professionals including breech within their sphere of practice access breech training from multiple providers, consider the underlying principles and how they fit with your own understanding and experiences of birth, and maintain an open mind.

The midwives of Portsmouth and the aftercoming fetal head

Claire Reading sharing her skills

Claire Reading sharing her skills

This Tuesday, 1 March 2016, Breech Birth Network travelled to Portsmouth again. The guest speaker was lovely doctor Ms Arti Matah, who spoke about an obstetrician’s view of vaginal breech birth, and led a lively discussion around whether the breech team / care pathway model might work for Portsmouth. Watch this space! I am incredibly impressed with the commitment Portsmouth midwives have shown to developing sound breech skills to support women who choose to birth their breech babies actively.

The skill which captured the group’s imagination most was how to resolve a situation where the head is extended and impacted at the inlet of the pelvis. My research suggests that identification of optimal mechanisms is a core skill for practitioners attending breech births. Therefore our approach to teaching this skill is:

  1. Identification of optimal mechanism — The aftercoming fetal head normally rotates to the oblique/transverse diameter as it enters the pelvic brim, just like the cephalic-presentation head does when engaging.
  2. Identification of deviation from optimal mechanism — In this complication, the fetal head is pinned in the anterior-posterior diameter, with occiput anterior, over the maternal symphysis publis, and chin or brow on the sacral promontory. The bottom of the fetal chin is felt like a ‘bird beak,’ pointing towards the sacrum. The maxilla bones are difficult/impossible to reach, so flexing the head using the usual techniques will be a challenge.
  3. Restore the mechanism — See below.

ShawnPortsmouthThe RCOG guideline suggests delayed engagement in the pelvis of the aftercoming head should be managed using one or both of the following techniques:

Suprapubic pressure by an assistant should be used to assist flexion of the head. Given our understanding of the head as impacted at the pelvic brim and our goal of restoring the mechanism by rotating the head to assist engagement, we suggest that the goal of suprapubic pressure should initially be to encourage this rotation. This mirrors the understanding we have of suprapubic pressure to resolve a shoulder dystocia by rotating the impacted shoulder off the symphysis pubis. Forcible pressure on an impacted fetal head is unlikely to be beneficial for the baby.

The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique to facilitate engagement. We use a doll and pelvis to explore why this elevation and rotation prior to re-attempting flexion is necessary. Watch the video below to see this demonstrated.

When a woman is birthing her breech baby actively, we facilitate the head to enter the pelvis using the same principles. Watch the video below, where Midwife Olivia Armshaw is teaching how  to intervene in the case of an extended head at the inlet, when the woman is birthing on hands/knees. In this video, the midwives are discussing how maternal movement – in this case, the woman shuffling her bottom back towards the midwife slightly – helps to elevate the head off the pelvic inlet to facilitate engagement, a technique we learned from the midwives of Sheffield. The principles – elevate, rotate & flex the head – are the same.

Thank you to the Practice Development Team at Portsmouth for organising the day. And thanks to the following midwives for assisting with the day:

  • Claire Reading, midwife in Somerset, who shared her breech experience gained working abroad, and facilitated one of the hands-on stations
  • Olivia Armshaw, midwife from Gloucester, who facilitated one of the learning station and presented on the process of developing a breech team in her local area
  • Tess McLeish, midwife from Lewisham who helped the day run smoothly

Our one sadness on this study day was that we were not joined by any of Portsmouth’s obstetric staff, aside from Ms Arti Matah, who needed to leave early because she was good enough to present at the study day following a night on-call. Across the UK, midwives are trying to engage their obstetric colleagues in a discussion about how to improve things for breech babies and their mothers, and we really need more doctors to come to the table for that discussion to result in a service which is as safe as possible.

Shawn Walker, Olivia Armshaw & Jenny Hall

Shawn Walker, Olivia Armshaw & Jenny Hall

BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!

— Shawn

Further Study Days are listed under Events. View our Training page for more information.

Feedback from the Study Day:

“the group work was excellent Overall I thought the day was was a good balance of theory to practical”

“very interactive. realistic rather than textbook. real life experiences.”

“perfect study day. Interesting and kept my attention all day!!!”

“visual with the film clips and hands on with the doll and pelvis. Was very good to see normal and abnormal films and great discussion with colleagues to share experiences and what to do in that situation.”

“I also thought Shawn’s attitude to breech was very refreshing. I half expected it to be a bit like “you can have a vaginal breech no matter what”. this was not the case. She had a very safe and sensible approach.”