Tag Archives: obstetric heroes

New RCOG guideline published today!

The new RCOG Management of Breech Presentation guideline has been published today. This guideline substantially revises recommendations in the previous version, published in 2006. If followed, it will undoubtedly improve women’s access to and experience of breech care. Below I will highlight two of the new guideline’s game-changing recommendations, and then raise two key questions concerning areas of on-going exploration.

Reference: Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG 2017; DOI: 10.1111/1471-0528.14465.

Victoria and Kirin Owal celebrate the healthy birth of their twins (#2 breech) with their NHS Team.

Counselling (Section 4.1)

The guideline offers specific recommendations around counselling, following the summary presented by lead author Mr Lawrence Impey at the RCOG Breech Conference in 2014. When discussing perinatal mortality, rather than focusing on the dichotomy between elective caesarean section at 39 weeks (0.5/1000) and planned breech birth (2.0/1000), the guidelines also recommend women consider these figures in light of those for planned cephalic birth (1.0/1000).

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This is important. If we follow the logic that has dominated breech care for the last 17 years – elective CS for all because it reduces perinatal mortality – we would need to apply this to planned cephalic births as well. The truth is always somewhere in between. All childbirth options carry benefits as well as risks, and women should be supported to apply their own values to decision-making, rather than feel obligated to adopt uniform recommendations arising from contemporary risk-focused discourse. This new guideline is much clearer about the obligation of health care professionals to present women with genuine breech childbirth options.

Maternal birth position (Section 6.7)

The guideline has changed from recommending lithotomy birth position to the following: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant.” This will be joyously welcomed by midwives and obstetricians who have been gradually incorporating upright breech methods into clinical skills training for some time, and the women who have been insisting on the freedom to choose their own birthing position.

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But as the explanatory notes indicate, “The principle difficulty with an all-fours position is when manoeuvres are required. Most obstetricians are more familiar with performing these in a difficult breech birth with the woman in the dorsal position.” This begs the question of how we will overcome the difficulty resulting from lack of obstetric familiarity with performing manoeuvres when women are in upright, particularly kneeling positions. Our recently published evaluation of the Breech Birth Network Physiological Breech Birth training days reported that one of the greatest concerns expressed by participants in the workshops was lack of involvement and collaboration from obstetric colleagues, whom they had difficulty convincing to attend the training in order to learn effective manoeuvres. Hopefully changes in our national guideline will prompt more interest.

Question #1: What does it mean to be ‘skilled’ in breech birth birth?

The word ‘skilled’ recurs 15 times in the new RCOG breech guideline. Variations include: ‘skilled intrapartum care,’ ‘skilled birth attendant(s),’ ‘skilled supervision,’ ‘skilled attendant(s),’ ‘operator skilled in vaginal breech delivery,’ ‘skilled support,’ ‘skilled personnel.’ Each reference suggests skill is a key ingredient of safe vaginal birth.

What does it mean to be ‘skilled’ in vaginal breech birth? Is it a quality possessed by individuals, or institutions, or both? How is skill assessed? How is it maintained?

The danger with lack of definition regarding breech skill is that by default it will be judged in retrospect. A good outcome occurs = the attendants were skilled. A bad outcome occurs = the attendants lacked skill and were overconfident in assessment of their own competence. A health professional attends four spontaneous breech births which do not require intervention = they are now perceived as ‘skilled.’

The guideline points to evidence from the PREMODA study, in which good outcomes were achieved in a study with senior obstetrician presence in 92.3% of cases. Association is not causation, but we need to take seriously the value the PREMODA researchers placed on this as a key to their success. In a UK context, or elsewhere, does that mean we can (or should?) reasonably expect all senior obstetricians to be ‘skilled’ at vaginal breech birth? What if the senior obstetrician does not feel ‘skilled’ her/himself? What if a midwife is the most experience person available to attend a breech birth?

The new RCOG guideline further recommends: “Units with limited access to skilled personnel should inform women that vaginal breech birth is likely to be associated with greater risk and offer antenatal referral to a unit where skill levels and experience are greater.” And: “All maternity units must be able to provide skilled supervision for vaginal breech births where a woman is admitted in advanced labour and protocols for this eventuality should be developed.” How will all maternity units be able to provide skilled supervision for undiagnosed breech births, if some of them will also need to be up front about their lack of skill to support planned breech births?

The new guideline recommends that “simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives.” The extent to which such simulation training will result in skill development in settings where skills have become depleted over the last 20-30 years is unclear. Our recent systematic review highlights the lack of evidence regarding the ability of standard training programmes to improve outcomes, and suggests that teaching vaginal breech birth as part of an obstetric emergencies course may actually reduce the chances that providers will actually attend breech births (Walker, Breslin, Scamell and Parker, 2017).

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The development of professional competence to facilitate breech births is a complex matter to which institutions may like to pay closer attention as they develop the ‘routine vaginal breech delivery service’ envisioned by the new guideline. Some of this complexity is explored in these two papers involving research with experienced practitioners: Standards for maternity care professionals attending planned upright breech births and Principles of physiological breech birth practice.

Question #2: What is a footling presentation?

Despite the acknowledged paucity of evidence regarding factors that increase the risks of vaginal breech birth, ‘footling presentation’ remains a clinical indication for advising women that the risks associated with vaginal breech birth are likely to be independently increased. Unfortunately, neither the guideline nor generally available breech literature provides a clear definition of what this means, nor is it likely that a similar definition has been used among disparate studies looking at outcomes associated with variations of breech presentation.

The danger with this lack of definition is that in many complete and incomplete breech presentations, where one or both legs are flexed, one or more feet will be palpable on vaginal examination. This is especially the case at advanced dilatation, when legs will often slip further down due to the increased space in the sacral cavity, into which the breech has also descended. And of course in advanced labour, the dangers of performing a caesarean section for a dubious indication are increased. It has never made sense to me to perform a caesarean section at advanced dilatation because one might need to perform a caesarean section! Where skill levels are minimal and practitioners are not taught to locate the sacrum as the denominator, many complete and/or incomplete breech presentations will be labelled ‘footling.’

Dr Susanne Albrechtsen teaching breech skills

In my practice, I follow the nomenclature suggested by Susanne Albrechtsen (unfortunately only available in Norwegian): a footling breech is one in which both feet present first, and the fetal pelvis is disengaged, above the pelvic brim. A fetus whose pelvis is engaged with one or more feet palpable alongside is a flexed breech (complete/incomplete).

We will await more professional debate and actual evidence concerning the definition of ‘footling breech’ and its association with fetal outcomes. Perhaps now that the new RCOG is more supportive of vaginal breech birth, more professionals will feel experienced enough to engage in discussions which will move our knowledge base forward and further increase the safety of breech birth.

Shawn

Stand up for those who stand up for you

Update, 24 August 2016: Following protests from the local and international communities, Dekalb Medical has reinstated the ability of Dr Bootstaylor and the See Baby Midwifery team to support planned vaginal breech births. Thank you to all who stood by the team and helped achieve this important result. More information.

21 August 2016: Within the past two weeks, restrictions have been imposed on two highly experienced breech birth providers, suddenly, and without apparent cause. They are currently not allowed to attend breech births in hospitals where they have done so successfully for many years. These restrictions have been imposed by others who hold power within the institutions. The providers who have stood by women now need women, families and other professionals to stand by them.

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On 7 September, a protest will be held in Los Angeles, California, at Glendale Adventist Medical Centre, which recently issued an outright ban on vaginal breech birth – The Rally Against Vaginal Breech Birth Ban. Glendale’s Dr Wu is a highly experienced breech birth attendant who supports not only women but other providers to gain skills.

If you attend the rally, or write a letter of support, and you tweet, use #bringbreechback – I will link to these tweets within this post.

Other related blogs:

The See Baby team of Atlanta, Georgia, have also been restricted. Their ban includes water birth and VBAC, as well as breech birth. Read more about their situation on the See Baby Blog. To support the See Baby team, I have written the letter below, sent to the Director of WI Services at Dekalb Medical. Please add your voice to protest this backward decision, addressed to the Director and copied to Julia Modest of the See Baby team, so that they are aware of the support of the international community.

On July 21, 2016, John Shelton issued a press release congratulating 83 of Dekalb’s physicians for being named as “Top Doctors” in Atlanta magazine — including Dr Brad Bootstaylor.

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PLEASE WRITE TO ADD YOUR VOICE

20 August 2016

To: [The Powers that Be, names and addresses removed now that resolution has been achieved]

 

I am writing to express my concern and disappointment at the recent, sudden decision of Dekalb Medical to issue a blanket ban on water births, breech births and vaginal births after caesarean section (VBAC), facilitated by the internationally regarded See Baby team. Such a decision directly contradicts the recent, positive movement to recognise birthing women’s agency and autonomy, as summarised in this recent statement from the ACOG Committee on Ethics:

“Forced compliance – the alternative to respecting a patient’s refusal of treatment – raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.” 1

The ban on water births and VBACs contradicts practices throughout the developed world, in which the tide is flowing very much in the opposite direction. My area of specialist knowledge is breech practice, where the tide is also turning, as reflected in the recent ACOG Practice Bulletin No. 161: External Cephalic Version, which also acknowledges the renewed interest in vaginal breech delivery as part of the movement to reduce the primary caesarean section rate.2 The change around breech birth is much more dependent on the skills of people like Dr Bootstaylor to light the way, due to many obstetricians having abandoned the art of obstetrics over the past several decades in favour of surgical deliveries.

The most recent ACOG Committee Opinion concerning “Mode of term singleton breech delivery,” written in 2006 and reaffirmed in 2016 makes clear, “The American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider.”3 This is also reflected in the FAQ information ACOG provides publicly to women.4 Dr Bootstaylor is one of the most experienced breech delivery providers in the country, and satisfies every criteria associated with a lower risk of adverse outcomes for vaginally born breech babies 5,6. I was privileged to teach breech skills alongside Dr Bootstaylor at a seminar hosted by Dekalb Medical in May of this year, which was attended by obstetricians and midwives from several surrounding states. This sudden decision will undoubtedly have local ramifications for the women whose birth plans revolved around Dr Bootstaylor and his very competent team of midwives. The restrictions will also have historic ramifications. Dekalb’s actions remove the option of vaginal birth from women pregnant with a breech fetus, and they also remove the option of health professionals to learn breech skills in a responsible and sustainable way, in a hospital setting with a highly experienced mentor.

Many women in the population served by Dekalb Medical go on to have one or more further children. The increased maternal and fetal risks associated with multiple caesarean sections are well-documented7, and removing the ability of this population to make an informed decision to avoid a first or subsequent caesarean section could be considered reckless. The high caesarean section rate is a contributing factor to the fact that the US is the only country in the developed world where maternal death rates increased between 1990 and 2013.8 While the decision to ban water birth, breech birth and VBAC was no doubt based on apparent increased short-term risks, the absolute risks of all of these choices are lower than they have ever been. I would ask Dekalb Medical to consider the increased recognition courts are giving to women’s right to autonomy, informed choice and respectful care9,10. In other settings, coroners and experts have specifically implicated lack of access to hospital-based care in the deaths of breech babies born at home 11,12. Dr Bootstaylor is one of the few obstetricians who truly work in harmony with other practitioners to make sure the door is always open.

Giving birth is a physiological process, not a treatment provided by a medical professional. In no other area of medicine are institutions or professionals ethically able to require patients to undergo surgery in order to access care at a time when their health is at risk. The choice of surgical intervention must always remain informed and freely made, or else it is coercion. As summarised in ACOG Committee Opinion No. 439, Informed Consent: “Consenting freely is incompatible with being coerced or unwillingly pressured by forces beyond oneself. It involves the ability to choose among options and select a course other than what may be recommended.”13

It is reasonable for Dekalb Medical to take a position and issue a recommendation to women regarding these options, if your experts feel they represent a higher risk of which women should be informed. That is the professional course of action. But disabling informed refusal of caesarean section is a clear case of medical coercion. Forbidding water birth is a disregard of the preference and comfort of hundreds of women, which will cause them emotional distress, with no evidence that such action will improve physical health outcomes for them or their babies.

Dr Bootstaylor and his See Baby Midwifery team are shining lights in safe, compassionate, woman-centred care. As Dekalb Medical were issuing this ban, I was writing about this team by invitation for an edited volume on sustainable maternity care. They are an exemplar of safe, sustainable breech care, a model for others to replicate. In my opinion, they still are exemplary and will still be featured. Although now the enduring lesson will be of how politics, power and money can undermine even the best practice and principles in medicine and midwifery.

Please may I ask that you forward this letter to the powers that be involved in the decision-making process to suspend these vital and exemplary services? I look forward to hearing that this dangerous and unethical action has been reconsidered.

Kind regards,

Shawn Walker, RM

  1. American College of Obstetricians and Gynecologists. Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. Obs Gynecol 2016;127:e175–82.
  2. American College of Obstetricians and Gynecologists. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol 2016;127(2):e54–61.
  3. American College of Obstetricians and Gynecologists. Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. Obs Gynecol 2006;108(1):235–7.
  4. American College of Obstetricians and Gynecologists. If Your Baby Is Breech, FAQ079 [Internet]. 2015 [cited 2016 Aug 20];Available from: http://www.acog.org/Patients/FAQs/If-Your-Baby-Is-Breech
  5. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189(3):740–5.

Summary: The presence of an experienced clinical at delivery reduced the risk of adverse perinatal outcome (OR: 0.30 [95% CI: 0.13-0.68], P=.004).

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

Summary: An expert panel consensus opinion that attendance at approximately 10-13 vaginal breech births is advisable for achieving basic competence, and 3-6 per year with mantaining competence.

  1. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.

Summary: The risk of maternal death from cesarean delivery compared to vaginal delivery is 2.7% vs 0.9%. Placental abnormalities (such as abnormal adherence, with consequent bleeding and possible hysterectomy) are increased with prior cesarean vs vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.

  1. Schumaker E. Maternal Death Rates Are Decreasing Everywhere But The U.S. [Internet]. Huffingt. Post. 2015 [cited 2016 Aug 20];Available from: http://www.huffingtonpost.com/2015/05/28/maternal-death-rate-in-the-us_n_7460822.html
  1. Birthrights. UK Supreme Court upholds women’s autonomy in childbirth: Montgomery v Lanarkshire Health Board [Internet]. Blog: Protecting Human rights childbirth. 2015 [cited 2016 Aug 20]; Available from: http://www.birthrights.org.uk/2015/03/uk-supreme-court-upholds-womens-autonomy-in-childbirth-montgomery-v-lanarkshire-health-board/

Summary: Women have a right to information about ‘any material risk’ in order to make autonomous decisions about how to give birth.

  1. Pascussi C. Mom Sues for Bait & Switch in Maternity Care [Internet]. Blog: BirthMonopoly. 2016 [cited 2016 Aug 20]; Available from: http://birthmonopoly.com/caroline/

Summary: A jury in Alabama unanimously returned a verdict in favour of a couple who experienced mistreatment and a lack of options in their hospital-based care, with an award including punitive damages of $16 million.

  1. Kotaska A. Commentary: routine cesarean section for breech: the unmeasured cost. Birth 2011;38(2):162-4.
  2. Powell R, Walker S, Barrett A. Informed consent to breech birth in New Zealand. N Z Med J 2015;128(1418):85–92.
  3. American College of Obstetricians and Gynecologists. Informed consent. ACOG Committee Opinion No. 439. Obs Gynecol 2009;114:401–8.

Compassionate breech birth in Bangladesh

So pleased to receive news via Twitter that physiological breech birth skills are being taught in Bangladesh! Tanya (@midwifeinbd) is doing a wonderful job collaborating with obstetric colleagues to change the way breech is taught and enable active breech birth.

Videos used in the training described above include The mechanisms, simplified, The Birth of Leliana and Shoulder Press and Gluteal Lift. You can read about ‘prayer hands‘ in this blog about assisting the birth of the arms.

Thank you once again to the mothers, midwives and doctors who have shared videos and birth images to enable health care practitioners all over the world learn these important skills.

Shawn

The Birth of Leliana

Jessica with Leliana

Image: Jacqueline Sequoia, used with permission

From Atlanta, back to Asheville

Jessica’s baby remained persistently breech at term, and she was unable to find a provider in South Carolina to facilitate a vaginal breech birth. When she attempted to decline a CS and negotiate a vaginal birth, she was informed that if she came into the hospital in labour, she would be given general anaesthesia and her CS would be ‘a lot rougher.’ (Folks, the ACOG published something just for you: Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy.)

This was Jessica’s first baby, in a frank breech position (extended legs), with no additional complexities. Her sister, Family Practice Doctor Jacqueline Sequoia MD, heard about Dr David Hayes and Harvest Moon Women’s Health because they were hosting my physiological breech birth training. Jacqueline includes obstetrics as part of her practice and booked to attend the workshop with some colleagues. Jessica and her husband Brian met with Dr Hayes to consider their options, and once Jessica made her decision, found a rental apartment in Asheville on Craigslist.

Let’s contemplate that for a moment. In order to have support for a physiological birth, rather than the threat of a coerced CS, women are having to relocate to another state and rent temporary accommodation, because the baby is presenting breech.

When Dr Hayes and I arrived at Jessica and Brian’s apartment, Jessica’s labour appeared to be progressing well. As people entered her space, Jessica gradually moved into the tiny bathroom at the back of the apartment, reminding me of Tricia Anderson’s metaphor of cats in labour. I turned off the light. This labour had a journey, as all labours have. Throughout her journey, Jessica was surrounded by people who love her. At the end of it, Jessica beautifully and instinctively birthed her little girl, Leliana, who weighed 7lbs 8oz.

This video contains graphic images of a vaginal breech birth.

Being attuned to the general lack of training in physiological breech birth among health professionals, and the consequences for women and babies, Jessica and Brian were keen to share this video of Leliana’s birth to help others learn. If you would like to read more about the minimally invasive manoeuvres used at the end of this birth, you can read our blog on Shoulder Press and Gluteal Lift.

brian

Thank you, Jessica, Brian, Leliana, Dr Sequoia and Dr Hayes for sharing this video. The link to this blog post can be shared, but the video cannot be downloaded or reproduced without permission.

Shawn

https://twitter.com/jsequoia/status/736602696115879936

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