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Breech Birth Training in Ethiopia

Last month I spent ten days in Southern Ethiopia volunteering for a charity, Midwives@Ethiopia (M@E).  The charity provides training for Ethiopian midwives and supports rural health centres to improve their standards.  This involves providing them with much needed essential equipment to help in the quest to improve maternal and neonatal morbidity and mortality.  My main role during the trip was to assist with the week training programme which was designed to teach midwives to safely manage obstetric emergencies in low resourced settings.  I was asked to teach vaginal breech birth and thought that this was the perfect place to run the Breech Birth Network’s Physiological Breech Birth study day, which teaches normal physiology and the skills to resolve complications of a breech birth (Walker et al, 2017).

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Discussing normal mechanism

In rural health centres in Ethiopia, the midwife’s hands are their tools and so what could be more perfect than to teach them a new concept to managing breech births where they could use their ‘tools’ to safely resolve complications should they arise. But also, to teach upright positioning of a breech birth which gives up to a 70% chance of the birth happening spontaneously (Louwen et al, 2017).  I was very nervous about the training, partly because this was such a new concept to the midwives, birthing in upright positions. “Women do not do that,” I was told. They informed me that women were “not cooperative” and therefore they gave birth in lithotomy positions.  I was not sure whether this was the case or if it was more to do with the well-known obstetric phenomenon of there being a bed in the centre of the room, so the person will just get on it because they think that is the right thing to do.  Or a lack of antenatal education on the importance of being mobile in labour.  This made me more nervous because upright breech birth was going to be so far from what they were used to doing and seeing, a bit radical!  The language barrier may also be an issue as well as the cultural differences, but I had nothing to lose and I really wanted to teach something which I believed would undoubtedly make a difference to mothers and their babies as well as to the midwives.

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Second stage birth room in Uddo Health Centre

I started the day talking about the midwives experiences they have had of breech births. Unsurprisingly to me all the midwives in the room had witnessed and facilitated breech births, there is no scanning available and so most breech presentations are
undiagnosed.  There is also limited access to health care for women and s ECV to turn the baby to a head down position is not usually an option.  There were thirty-seven midwives present from different health centres and some from the main hospital in Dilla.  Their experience ranged from eight weeks qualified to seven years qualified however some had very limited clinical experience in this time. Such as Getnet, the head of midwifery at Dilla University, he had six months clinical experience and has been working non-clinically for five years teaching midwives.  I was struck by their stories of how women would walk for miles in labour to access help from a health centre because their labour had been obstructed, the breech presenting baby would be half born and they needed assistance to complete the birth of the baby.  If they called an ambulance it could take hours to reach them, if it arrived at all, and they could then have a two, three, four hour or more transfer time to the nearest hospital for obstetric assistance.  It is no wonder the maternal and neonatal morbidity and mortality rates are so high.  However, the Government is working hard at improving the morbidity and mortality rates with the help from the WHO and other organisations such as M@E and they have met their goal of increasing safety for mothers and babies early which is a fantastic effort and must be recognised.

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Nenko, M@E’s main contact in Ethiopia who works with WHO

Health officers such as Nenko are vital in the quest to improve maternal and child health.  They work very closely with the WHO and charities to bring training and help from other areas to improve safety for mother and child.

After finding out about their experiences I taught the normal mechanisms of a breech birth.  I emphasised how birthing in upright positions will assist with the birth, widening the pelvis by up to 1.9cm (Reitter et al, 2016). I used a flexible pelvis to demonstrate this at every opportunity and referred it to cephalic birth as well, so they could see how women birthing in upright positions can help for all births.  I had the help of two excellent midwifery lecturers, Kiddist and Shimeles.  Kiddist is a lecturer at Awassa University about three hours north of Dilla, she has many years of experience and left Ethiopia briefly to complete her Masters in Amsterdam.  Shimeles has seven years of clinical experience before becoming a lecturer at Dilla University and is now interested in moving into research.  Their English was excellent, so they were able to help with the translation, this was a very new way of teaching breech birth for them to, but they were enthralled listening intently and repeating everything I was saying in Amharic to ensure understanding.

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Kidist and Shimeles, Ethiopian Midwifery Lecturers

Something which I have always found very surprising is the lack of knowledge about the normal mechanism of a breech birth, like I found so many times when teaching in the UK, the Ethiopian Midwives were also unclear about the normal mechanisms prior to the training.  This was evident by their answers to the pre-course training questionnaire which I had asked them to complete prior to starting the training.  Twenty-two of the midwives thought that as the Frank breech passes through the ischial spines of the maternal pelvis, the fetal sacrum is normally anterior.  This is the most common thought, although the actual answer is sacrum transverse.  This is misconception is possibly due to traditional breech training focussing on telling practitioners that the back must be uppermost, however the rotation to sacrum anterior occurs after the birth of the buttocks so the rotation is visible and should be noted as a reassuring sign of progress.

After lunch it was time to teach how to quickly recognise complications and resolve them working with physiology.  During breakfast I had given two other M@E volunteers a crash course on the resolution of complications, so they would be able to assist with the teaching during the day.  When I spoke about and taught a complication I would show the manoeuvre for resolving the complication by teaching Shimeles and then ask him to show the group with me. Shimeles was then able to assist with the teaching which meant we had more time to ensure all participants were able to correctly perform the manoeuvre and had good understanding of what they were doing.  I was pleasantly surprised at how enthusiastic everyone was and how well they picked up these new manoeuvres.  I started with simple shoulder press, I talked through when to use it and how to perform it and showed them videos of the manoeuvres being used.  They found this particularly useful.  They then all took it in turns to come up and perform the manoeuvre with either myself, Haf or Shimeles.  This was a simple manoeuvre for assisting with the birth of the fetal head if it is deflexed at the outlet possibly due to the cord being around the neck or to speed up the birth due to a fetal concern.  It was a manoeuvre they all felt they could use in practice which was easy to perform and very effective.  I then taught shoulder press with ‘rock and roll’ which they thought was very amusing.  Again, I taught Shimeles, he translated and performed the manoeuvre with me and then the group practiced.  Shoulder press with ‘rock and roll’ can be used for a head in the mid-pelvis which has not fully flexed or if simple shoulder press has not been successful.  Many of the midwives preferred this version of shoulder press to the simple shoulder press because they felt more secure holding the baby in this way.

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It was lovely to see such enthusiasm for learning something new and the ‘light-bulb’ moment when they understood how birthing in upright positions can reduce the need for intervention which, for them, working in such low resourced settings and with extremely long transfer times in to an obstetric facility, was so important to have skills which would surely help to successfully assist breech births and potentially reduce harm to mother and baby.  I held onto this enthusiasm as I continued through the course of the afternoon teaching how to recognise and resolve a compound arm by sweeping down the anterior arm.  How to recognise and resolve using rotational manoeuvres with ‘prayer hands’, an anterior nuchal arm or bilateral nuchal arms. This is the complication which they found the hardest to grasp, the manoeuvre requires rotation to sacrum transverse, sweeping down the anterior arm under the pubic bone before rotating back to ‘tum to bum’.  It required much more practice than the other manoeuvres but after a few attempts each they also were able to resolve this complication confidently.

After the arm complications came the head complications.  The most feared of complications by healthcare professionals in any country is an extended head at the pelvic inlet.  This was also true here in Ethiopia, where on the pre-training survey many commented about this complication:

“…delayed engagement of the after-coming head to save both fetal and maternal life.”

It was clear this complication was misunderstood as it is by so many healthcare professionals.  It is due to the lack of knowledge about the physiology of a breech birth that this complication is so feared and difficult to manage.  One of the questions on the pre-training questionnaire asks about how a practitioner would resolve delayed engagement of the aftercoming head, the answers confirmed the lack of knowledge and understanding of the complication.  If this is not taught to healthcare practitioners how are they supposed to resolve the complication?

“after deliver of arm and lower extremities then deliver the head by MSV manoeuvre/procedure”

“…with piper forceps, by doing cervical incision.”

“Apply MSV…manoeuvre to deliver the head if after this manoeuvre still the head is not deliver apply piper forceps.”

“We use MSV manoeuvre and simultaneously apply supra pubic pressure.”

I taught them how to use a manoeuvre called ‘elevate and rotate’ describing the physiology behind why the head does not engage and becomes impacted at the pelvic inlet on the sacral promontory.  Once they understood this, the manoeuvre came easily to them.  They watched it on a video and had many goes at practicing it. This manoeuvre was so important for all of them to learn but in particular those working in rural health centres.  Having heard the stories they shared throughout the day about obstructed breech births and not being able to resolve these complications, I knew that even if a woman had spent hours walking in labour for assistance, it may be too late to save the baby, but these manoeuvres could still help to save the mother.  It really struck me how their challenges were so much different to ours back in the UK, how lucky we were to have obstetric assistance at our finger tips within minutes. It puts everything into perspective and changes your views on many things within midwifery when you hear these stories and challenges which they face every day when they go to work.

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At the end of the day I was given a traditional Ethiopian applause and cheer, I knew at this moment I had taught them all something which they could use, something that would really make a difference to their practice not only with breech birth but quite possibly with cephalic births too.  I hope to return to Ethiopia next year and be able to train more midwives these invaluable skills, so they can help more mothers and babies safely enter this world whatever position they decide to present in!

— Emma Spillane

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. 

celebrating becoming a mother

Today is my first son’s birthday. I’ve decorated the cake, packed the basketball tournament lunch, gathered the little presents. Ely’s birth set me on a path, and the love I have felt from the moment he was born knows no other. So I’m celebrating by posting a poem I wrote about giving birth. This birth was Waldo’s, my second son.  Birth is life.

early ely

early days with Ely

Morning Story
for Waldo Myles Capability

we are what gets written –
we are what blooms

you move and I echo

the story written in my body
to tell over again with twists and groans –
the story written in your body to seek out –
memory, the river which threatens and feeds

you move and I echo

my body uncurling from the pain of release –
your body uncurling from the pressure of flight

you move and I echo

mom and me

my mom & me

we who risk failure
and lunge into our song

you move and I echo
my own primary call

The story of you emerges
wearing its caul
of tea and toast
and breast and boast
in the ecstasy of our achievement.

Each time the shell of me breaks
I am larger and louder –
more full of wind
and song and thanks –

for the day you were born.

Bottoms Down Under

‘Into the Breech’ Workshops in Perth and Melbourne, December 2013

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Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits

This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.

The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.

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Anke Reitter frisking Andrew Bisits .. while demonstrating how to release stuck nuchal arms.

Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.

Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.

Dr Rhonda Tombros

Dr Rhonda Tombros

A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.

Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.

Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:

  • Exif_JPEG_PICTURETry to sweep down the arms in front of the face
  • If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
  • Ensure the head is aligned with the body and the mother’s birth canal
  • Deliver the head using classic or modern techniques to achieve flexion

The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.

But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.

Shawn