Happy new year, breech advocates! We’ve got nearly 10 hours of evidence-packed, video-rich, detail-loving breech birth training content waiting for you.
Our fully updated 2022 course is now on-line. To help you reach your new year’s resolution of developing some beautiful breech skills, the course will be available at a discounted price of £50 for the first two weeks of January. No code needed; access is for one year.
Along with a new course, our Vimeo library has a NEW PASSWORD. This is available from the “Resources for Teaching and Implementation” section of any course you are enrolled in, along with our amazing Dropbox of guidelines and training resources. Registered users have permission to use the content for non-profit teaching purposes — because learning together is the safest, most effective way to do it.
All of our online courses also come with free access to our Online Webinars. These are one-hour discussions on topics that have arisen during the course of our practice or others’, where we share learning and reflection with each other.
If you have previously completed any of our on-line courses, you are eligible to register for the Refresher course for only £10/year. This is exactly the same as the main course, but for a nominal cost to help us keep our platforms online. You can review the course, or just complete the assessment to obtain a new certificate for your portfolio.
Anyone organising or attending one of our face-to-face courses will be given free access to the on-line course for one year. Due to the on-going pandemic and need for social distancing, we rarely have external places to offer as we did pre-2020, but you can still host a study day for yourself and your colleagues.
If your site is participating in the OptiBreech Trial, your free online training package has already been updated.
What if I have attended an in-person course in the past? Access to the Refresher Course is only available to those who have purchased and completed one of our on-line courses, beginning in 2021. All of our previous courses have been advertised with one year’s access to our Vimeo Library. Content is updated regularly, so our recent courses are significantly expanded, based on current research, compared to those of previous years. If you have completed the main course, the system will automatically consider you eligible to take the Refresher. If you use our videos for teaching within your institution, we encourage you to ask your employer to reimburse your training so you can continue to maintain access.
Finally, some opportunities to become more involved in Breech Birth Network. We would really like some help with the following, and if you are willing to make a regular commitment and develop the skills necessary, we can also pay you! Emma and I developed the skills to do all this because that is what was necessary, and we know others can too.
Ideally, we would like to involve people who are supporting breech births professionally in some way, so that the learning that occurs in these roles also spills over into developing your own practice. That’s what makes it worthwhile for us. And obvs, we expect that you would have completed our training to know what you are getting into and that your approach to breech birth aligns with ours.
Online Webinatrix. We do our online webinar series ad hoc at the moment, but we’d like it to happen regularly.
Video Master. We have a large Vimeo library, but in order to make the most of it, it needs to be organised — edited, tagged, consent forms stored securely, etc.
Online education Diva. In addition to developing new content based upon new evidence or learning from practice in our communities, we have a need to develop translated versions of our courses to make them more accessible to a wider audience. We use Articulate 360 and WordPress, and although we don’t expect you to come in with those skills, we need someone who is willing to develop them to get the job done.
Accounting Guru. This doesn’t necessarily need to be a birth professional. We use Xero, and our amazing admin assistant Charlie has been doing this for us for a few years, but now needs to hand over due to other exciting things happening in her life.
If you are interested in any of these roles and prepared to make a commitment to helping our small, not-for-profit enterprise grow, please get in touch using the form below.
Breech Birth Network are pleased to announce the publication of an evaluation of our physiological breech birth training, conducted in eight NHS hospitals across England and Northern Ireland. Click on the image below to read the full evaluation.
Multi-disciplinary training, involving NHS midwives and obstetricians
Only training to have demonstrated an increase, rather than a decrease, in vaginal breech births following delivery of the training package, although this was not statistically significant
Use of upright positions at birth increased significantly
Pilot data: no adverse outcomes among births attended by someone who had completed the training, compared to a background rate of 7%
Pilot data: perineal outcomes similar to cephalic births
Congratulations to midwife Stella Mattiolo, who collected and analysed this data as part of her Masters in Research.
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful new series of training videos for upright breech birth. We are thrilled to be able to share them with you!
The creation of the videos was led by obstetrician Kamilla Gerhard-Nielsen, who also led the implementation of the upright breech concept in the hospital and its introduction in Denmark.
They also host a FaceBook page. Image: Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen
Providing advanced training to a core breech clinical teaching team is potentially more efficient and effective than training the entire maternity care team using traditional methods. The theory is strong, but rigorous research needs to be done.
Traditional training, looks something like this: Participants take time away from clinical commitments to attend a dedicated training session, ranging in length from a few hours to a whole day or more.
Challenges for this approach in the context of breech birth
1. It’s expensive
While preparing the research proposal for the #termbreech2020 Physiological Breech Trial, I worked closely with NHS Research & Development Finance specialists. Using the Agenda for Change pay scales, we calculated that providing 1 day of physiological breech birth training to 5 obstetricians and 5 senior midwives will cost the service £2,442 just to release them from clinical work. Multiplying this to cover the whole staff will obviously increase the cost exponentially. And then there is the cost of paying the trainers.
This is why most training programmes, like PROMPT, use a ‘train the trainers’ approach. It is a more efficient and effective way to disseminate training throughout an organisation. [PROMPT is a great multi-professional training package, but unfortunately, they excluded outcomes for breech births from their evaluation (Draycott et al 2006). So this training has not yet been evaluated for vaginal breech birth.]
2. The effects of training wear off before most people will have a chance to use it
Our systematic review of the effectiveness of breech training strategies showed that breech training can improve objectively assessed skill and knowledge, but that these effects wear off quickly, sometimes within 6 weeks, sometimes within 72 hours. A bigger concern was that, in some cases, confidence increased but objectively assessed skill did not. Training alone is likely not sufficient to improve breech skills, but for those who have some clinical experience, it may extend current understanding.
If you train a staff of 40 (or more) in a service that has only 1 breech birth per month, most of them will not have a chance to consolidate their learning in clinical practice. And if you do not have a plan for ensuring that someone who has attended enhanced training will attend the vaginal breech births that do occur, the enhanced training will not contribute to improvement in outcomes.
3. Clinical support in practice appears to make the biggest behavioural change
A surprising finding from our systematic review was that attendance at an obstetric emergencies-type training course was inversely associated with attendance at vaginal breech births, unless a system was in placed to provide clinical support in practice. This means that clinicians attended fewer vaginal breech births after taking breech training as part of an obstetric emergencies package. Although no quantitative evaluation was done, the studies that reported increase in breech births attended all had a model for ensuring experienced support in practice.
Implementing a breech clinical teaching team is a way of ‘training everyone.’ The model just differs from traditional ‘training day’ methods, which have not proven effective on their own in sustaining safe vaginal breech services.
Paying a few people who want to support breech births to be on-call occasionally and to cascade training is likely less expensive than providing enhanced training to the entire maternity care team, or even the entire senior team. But we need to implement the model and evaluate it in a systematic way in order to determine cost effectiveness. This is why experienced health economists are central to the #termbreech2020 Physiological Breech Trial and helped develop the design.
According to the evidence, breech clinical teaching team is also likely to result in greater availability of the option of vaginal breech birth for women who want them. This was a central concern of the women who participated in #termbreech2020 Physiological Breech Trial public engagement work.
But! Isn’t experienced senior clinical support what consultant obstetricians do? … Good question. We’ll discuss that next …
Dr Anke Reitter and Dr Shawn Walker of the Breech Birth Network will teach together in Barcelona on 23 April at Hospital de la Santa Creu i Sant Pau. Please share with your obstetric and midwifery colleagues. Materials will be translated into Spanish for participants. Click the image below for more information on how to register.
Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth. Unfortunately, anecdotally this does not seem to be the case for all. Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term. Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth. Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down. More decisions have to be made, that’s if the choices are offered to parents. Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way. The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment. In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first. Additionally, the skill of the practitioner is key to ensuring safety. The RCOG states:
“The presence of a skilled practitioner is essential for safe vaginal breech birth.”
“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”
But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births? This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.
The first step to gaining knowledge and experience is to become involved in teaching. This has many benefits including, increasing your comprehension and embedding that information so you can pass it on to others; enables people to recognise you as breech specialist and it helps to build confidence when discussing with colleagues and parents alike. The more you are teaching the greater your understanding and the more people will recognise you within this role as a breech specialist. It is vital to keep your own skills up to date if you are putting yourself forward as a specialist, teaching both locally and assisting with teaching through the Breech Birth Network, CIC will help you keep up to date with the latest evidence and move things forward within your own constabulary. The team at the Breech Birth Network, CIC are very keen to support others to teach on our Physiological Breech Birth courses. You can read the following blog post for more information on the benefits of teaching Physiological Breech Birth with the Breech Birth Network, CIC.
Other ways to get involved with teaching are within the University and to the students coming through the local hospitals, these are the midwives of the future and this is where the biggest change is going to come from. Likewise, speak with the lead Consultant Obstetrician for new doctors starting in your Trust to see if you can teach them a shorter session on their induction days. This enables the new doctors coming into the hospital an awareness of what will be expected of them in terms of offering choice and ensures they have an understanding of both the mechanisms of breech birth and recognising complications. Additionally, setting up a weekly morning teaching session for thirty minutes ideally after handover so those finishing the night shift and those starting the day shift can both attend. This can be done as a case discussion or a scenario using a breech birth video. You could even use a breech birth proforma (if you have one) and ask those attending to complete the proforma whilst watching a video to see if they understand about the timings for a physiological breech birth and when to intervene. Speak to the Practice Development team and ask if you can teach the breech sessions on the mandatory training days too – moral of the story…teach, teach, teach!!
Of course, with all this knowledge and skills you are teaching you need to put it into practice. Put yourself forward at every opportunity to attend breech births both to facilitate them yourself and to support others to gain confidence in facilitating vaginal breech births. Clinical experience is essential. Research has shown, to maintain skills and competence the breech specialist should attend between three to ten breech births every year (Walker, 2017; Walker et al, 2017; Walker et al, 2018). In some smaller units this may be difficult to achieve but by making yourself available to attend births you will have a far better chance at getting these numbers in practice. There is also evidence which suggests that you can create the same complex pattern recognition by watching videos of vaginal breech births, both normal and complicated, as you can by attending breech births in real-life (Walker et al, 2016). Watching videos has the added benefit that you can rewind and re-watch parts of the video to ensure understanding and further analysis.
Setting up a breech birth service would be an excellent next step. Firstly, find a Consultant Obstetrician who is supportive of physiological breech birth and who would help to lead on service development with you. This has to be a multi-disciplinary approach other wise it just won’t be sustainable or safe. The best way to move such services forward is with consultant support and input, don’t try and do it on your own. A breech birth clinic is a good starting point for any service development, this will provide midwife-led and consistent counselling for parents attending the clinic. Depending on the size of the hospital, running the clinic once a week should be adequate initially. Setting up a dedicated email address for all referrals to be sent to is a great way to ensure referrals are not missed and there is a clear pathway set out. The following is an example of such a pathway:
Referrals can be made by any healthcare practitioner, but it is a good idea to link in with the sonographers performing the ultrasound scans. They may be able to send the details of the mother via email immediately following the scan and give the parents an information leaflet. This avoids any delay with the referral being made by another healthcare practitioner and ensures the counselling remains consistent. Moreover, the development of ‘breech teams’ is supported in the literature to ensure there are breech specialist midwives and doctors on every shift, or on-call, to support the wider team to gain their clinical skills to facilitate vaginal breech births and increase safety for mother and baby.
To further develop the service and your own skills you could complete a midwife scanning course. This will enable you to scan mothers referred into the breech service to check presentation before sending for a detailed scan. The advantages of this is that mothers could be referred into the clinic earlier, from thirty-four weeks gestation based on identification on palpation. Research has shown mothers find it difficult making decisions about mode of birth for breech presentation so late in pregnancy and would benefit from earlier referral and discussion. Referrals made at thirty-four weeks gestation with a bedside midwife scan to assess presentation, would enable the counselling to begin sooner giving more time for decision-making. An additional advantage of being able to scan is following mothers up after successful external cephalic version (ECV). Seeing mothers, a week after successful ECV enables you to scan the mother to ensure the baby has remained in a head-down position avoiding unexpected breech births. An adjunct to the scanning course would be to learn to perform ECV’s. This enables a fully midwife-led service and research has indicated comparable rates of success for ECV’s performed by Midwives and those performed by Obstetricians. It is also cheaper for the Trust to have ECV’s performed by Midwives!
Governance and audit are the final steps to take to building the specialist breech midwife role and for service development. This is often seen as the mundane part of the job, but you will benefit greatly by doing this, not just from immersing yourself in all the research but by knowing your service inside and out. Knowing what needs to be changed and what has improved. The first step in governance change is to write the guidelines incorporating physiological breech birth, new evidence relating to breech presentation, service development, the breech clinic, referral pathways and training. An example of a current guideline can be found via this link. Develop an information leaflet to give to parents which contains the latest evidence in relation to breech birth options. It can be given to the mothers either by midwives in the clinic and/or by the sonographers after their ultrasound confirming breech presentation. The following can be used as an example and is editable for use in your organisation.
Finally, audit, audit, audit! Before, after and everything in between! This is your evidence that things need to change and, once the service is developed, the outcomes since you implemented all the aspects of the service. It will also act as evidence of safety which the governance team within the organisation will want to see. Audit rates of planned caesarean, emergency caesarean, planned VBB, successful VBB, neonatal outcomes, maternal outcomes, uptake of ECV, success rate of ECV etc. All before and after the service. It is also a good idea to obtain service user feedback. Developing a simple questionnaire such as this one enables you to easily send and receive feedback regarding the service. Feedback from service users is the most powerful way of moving services forward and supporting change within an organisation, it also enables you to develop the service dependent on the needs of the parents using it. The process of audit and user feedback is continuous throughout the time running the service. However, it is important analyse and present the result at regular opportunities such as at local level with clinical governance days and meetings and at a wider national level at conferences and in journals.
Whilst it can seem daunting and places you in a seemingly vulnerable position, starting your journey as breech specialist is an extremely rewarding one which will enable you to learn and develop new skills not just clinically but operationally and strategically. It will give you a stepping stone into research, audit and teaching, build your confidence as a practitioner and most of all, empower you to provide the best evidence-based care for those families who need that knowledge and support at a crucial time in their pregnancy to help them to make the right decision on mode of birth for them and their breech baby.
Following the implementation of all that has been discussed in this post, the results within the large teaching hospital I work are as follows:
Planned caesarean section increased from 55.8% (n=43) to 62.9% (n=66);
Unplanned caesarean section decreased from 42.9% (n=33) to 24.8% (n=26);
Vaginal breech birth increased from 1.3% (n=1) to 12.3% (n=13)
All results are for those over thirty-six weeks gestation, there were no differences in neonatal mortality or morbidity prior to or following the implementation of the service. This is a positive change and shows how supporting vaginal breech birth in a safe environment can increase the normal birth rate. The results are after a year of implementing the service and will hopefully continue to improve as time goes on and more midwives and doctors become more confident to facilitate breech births.
This weekend, I have been lucky enough to visit Stockholm, Sweden, at the invitation of the Södersjukhuset (BB SÖS), with Dr Andrew Kotaska, author of the 2019 Canadian breech guideline. We delivered training in breech research and practice to obstetricians and midwives from across Stockholm, a contribution to their recent effort to establish city-wide guidelines.
Breech Team Leader Tove Wallström and Breech Midwife Monica Berggren
The day was organised by senior obstetrician Julia Savchenko (pictured with Andrew above). Julia and fellow senior consultant Tove Wallström lead the Labour Ward and the SÖS breech team. These inspirational women presented their local audit results, showing how their vaginal breech births have increased from 9 in 2014 to 50 so far in 2019. Almost all women give birth in an upright position, and all births are attended by a breech-experienced obstetrician and a breech-experienced midwife from the breech team.
Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre
After training with the Breech Birth Network, Isabelle Brabant gave us her feedback from her first training session teaching midwives in the far North of Canada:
“I have to tell you a bit about Maternity up North. There are seven villages on the Hudson Bay Coast (just about 1200km long!). There’s a maternity service in three of the biggest villages: Salluit, Puvirnituq and Inukjuak. There is no road to get there, you can only go by plane or by cargo – if you have a couple of weeks to spare for the trip. The Inukjuak maternity services have around 40 births per year, and if a baby remains breech in the pregnancy they would offer an external cephalic version, but if unsuccessful the woman would be sent to services further south (to Montreal!) to have her baby – alongside the other approximately 15% of women who are referred for medical reasons. If ever a woman needs to be transferred in labour it takes no less than 8 hours as there is no plane in the village itself – yes 8 hours! In an undiagnosed breech situation the decision would be made to transfer, but the chances are that the baby would be born before transfer. This explains the interest and need for Breech Birth training with the midwives being very interested in the training – of course they have a small volume of births, but the possibility remains of having an undiagnosed breech birth at any time.
The training was given to a small group of enthusiastic midwives in Inukjuak, where we started the day with what is normal for Breech which the midwives enjoyed alongside teaching essential skills and manoeuvres. I will be delivering this training three times to Quebec midwives in May and June.”
There are three more training sessions planned in Canada throughout May and June and the details are as follows:
6th May 2019: MdN de l’Estrie, Sherbrooke
31st May 2019: MdN Mimosa, Lévis
13th June 2019: Montréal (lieu à déterminer selon la taille du groupe)