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

Bruxelles et le siège

Training in Lewisham on November 12 — Book here.

“We believe that we do well what we do often.” – Caroline Daelemans

Drs Caroline Daelemas and Sara Derisbourg

Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.

This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.

I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.

Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme

My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.

The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”

Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press

Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.

Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)

What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)

All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.

If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.

— Shawn

India and the breech

Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:

PMET student Arunarao Pusala receives her training certificate in Karimnagar

This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.

with Senior Midwives Theresa and Jyoti

The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.

Midwives and doulas support women together in the beautiful Stork Home facility in Hyderabad

From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!

Shawn

Rotational manoeuvre to release breech nuchal arms

flat hands

In June, I spent a week in the Netherlands working with a committed group of lecturers. The midwifery universities of the Netherlands share a common curriculum, and following our meeting last year, they agreed to incorporate physiological breech birth into their training programme. My visit was to support the midwifery lecturers to implement the new skills into standard midwifery training.

While in Amsterdam, I collaborated with Midwifery Lecturer Bahar Goodharzi of Academie Verloskunde Amsterdam Gröningen (AVAG) to create a short series of films demonstrating the rotational arm manoeuvre we teach in Breech Birth Network study days. We agreed that this is a tricky manoeuvre to learn and teach, but it is incredibly effective in practice so worth the effort of learning. I’ve collected our short demonstrations in the film below, along with information about how to recognise that this manoeuvre is required.

Note: If you have difficulty rotating the baby initially, you may have to elevate the baby slightly to a higher station, so that the shoulder girdle rises above the pelvic inlet. It can then rotate to engage in the transverse diameter.

Thank you to Emma Spillane of St George’s Hospital in London, who has helped to refine the way we teach this manoeuvre following her own experiences of successfully using it in practice.

For a poetic description of what it is like to encounter this complication for the first time as a midwife or doctor, read Nicole Morales’ blog, The prose of no rotation and no descent: rotating to free the arms.

You can download the Physiological Breech Birth Algorithm here.

Midwifery Lecturers of the Netherlands, June 2018

— Shawn

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. 

Building confidence and changing practice through participation on training days

Emma Spillane

Emma Spillane, Training Co-ordinator at the Breech Birth Network, has attended six breech births in the last six months in an NHS hospital. Rebuilding breech skill is possible, guided by evidence about how breech competence develops. Emma writes about how she gained confidence in teaching and attending physiological breech births by assisting at Physiological Breech Birth study days.

In January 2017 I attended a Physiological Breech Birth study day in Norwich by Dr Shawn Walker and Dr Anke Reitter.  Breech birth had always interested me from my first breech birth as a newly qualified midwife.  I didn’t understand the physiology of breech birth at this time, it had always been taught as something abnormal, an obstetric emergency.  I could never understand though, how breech birth could be so abnormal if babies were on occasion born like this.  My interest had been piqued, and so a few years later, and a few more breech births later, I found myself on the study day to develop my knowledge and skills in vaginal breech birth.

The study day taught me the tools required for supporting women to have a physiological breech birth and to resolve possible complications whilst supporting physiology.  Following the training I went and introduced myself to Shawn and told her of my interest in breech birth, I felt so inspired to start a breech birth service within the trust I work.  On my return to work I started putting plans in place to develop a service within the trust.  Shawn contacted me  a few days later and invited me to help teach the hands on clinical skills on her next Physiological Breech Birth training day in South Wales.  I jumped at the chance to attend and found it so useful to listen to the day again and then help with the hands on teaching.  It helped to embed what I had already learnt previously and give me the confidence to teach the skills within my own trust.

I started talking about breech, a lot!  Shawn continued to invite me to help on training days and with each one my confidence grew. I started viewing the videos differently. Instead of looking for what was ‘normal’ and ‘abnormal’ I started analysing them with a deeper understanding of the physiology.  Shawn also encouraged me to start teaching parts of the presentation. Admittedly I was more than a little ropey to begin with but with Shawn’s nurturing and encouragement and the more I learnt from each training day, each time I attended my confidence grew.  Eventually I was able to transfer this new knowledge, understanding and confidence into practice.  I was asked to attend a breech birth!

I supported a woman with a physiological breech birth, along with a consultant obstetrician colleague and one other midwife.  An arm complication occurred with the birth, and I was able to resolve using the manoeuvres I had learnt and taught on the course. The baby was born in good condition, and I felt relieved and elated!  I immediately contacted Shawn to tell her about the birth but it had also sparked an interest in the consultant obstetrician who had attended. We debriefed from the birth and I spoke about the Breech Birth Network and the training it offers.  I took the opportunity to ask if my obstetric colleague would like to be the lead consultant in my quest to set up a breech birth service, to which they agreed.  It had taken me nine months – the length of a full term pregnancy – from when I first attended the training until this physiological breech birth. It was the birth of an exciting change in knowledge and culture.

Claire Reading, Emma Spillane and Shawn Walker

Attending training days has not only helped to embed my own learning but it has given me the skills and confidence to set up a service within the trust I work, support women who choose to have a vaginal breech birth and support colleagues to facilitate breech births themselves.  I have found repeating the information and skills has been the key to my learning and enabling change within practice. It has given me the confidence to attend births and increased the number of breech births within the trust by instilling confidence in others.  If you would like to build your confidence in vaginal breech birth, develop a service within your trust and teach others I highly recommend coming along and helping at future training days. You can view a list of upcoming opportunities to help deliver training here. Please let us know by getting in contact via email or the contact form.

Emma

Research indicates that providing teaching is an important part of the development of breech expertise. Read more: Expertise in physiological breech birth: A mixed-methods study