Breech training in Paris, November 30 & December 1. Places still available. Download complete poster for more information.
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.
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.
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
The Breech Birth Network visited Belfast this weekend. Dr Anke Reitter FRCOG of the Krankenhaus Sachsenhausen and I taught a day-long physiological breech study day at the Royal Victoria Hospital for over 40 obstetricians and midwives.
The day was organised by Consultant Obstetricians Janitha Costa and Niamh McCabe, enthusiastic upright physiological breech practitioners, and Senior Registrar Shaun McGowan. The team have recently published outcomes associated with their breech clinic (Hickland et al 2017 and Costa 2014).
Our study day increasingly emphasises pattern recognition and decision-making through the use of real breech birth videos, especially videos of complicated births. We watch, deliberate and critique – with compassionate understanding, respect and humble appreciation. These brave health professionals and women have allowed themselves to be vulnerable and exposed in order that others may learn, and we are very grateful.
We have also moved away from using heavy and expensive simulation models and rely instead on doll and pelvis models. These enable us to see what is happening from all angles and embed the theory of the manoeuvres we are teaching. We operate on a see one (the theoretical presentation), do one (hands-on with one of the instructors), teach one (of your colleagues) model. This helps build confidence to carry on teaching the techniques in the local setting.
Our preferred models (it’s a great idea to have some on hand if you are organising a study day or implementing this training in your local setting) are:
Fetal Doll Model; and
Final announcement: Blogging has resumed because … I submitted my PhD a couple weeks ago! Hurrah!
(See the Catalan version of this article below …)
This week (21-22 March 2017), the Breech Birth Network was in the beautiful city of Barcelona, at the invitation of the obstetricians and midwives of Hospital Sant Pau. Our team expanded for the occasion! Midwife Maria Segura translated all of our teaching slides into Catalan. And Cardiff-based midwife Carmen Rubio ensured everyone had an opportunity to receive hands-on help when practising manoeuvres to assist women birthing in upright positions.
I love studying and teaching physiological breech birth most because when a health professional learns how breech works, they learn how all birth works. Despite its apparent applicability for only a small proportion of the total population, skill in the art of facilitating breech birth resonates throughout a professional’s entire birth practice, their collaborative work with colleagues and within institutions.
Our experience in Barcelona made this clear. Hospital Sant Pau is in a period of transition, trying to increase the rates of normal birth. Breech birth is a part of that, but midwives are also working to establish the first midwifery-led birth centre in Catalunya. The hospital has recently established a new guideline enabling obstetricians to support physiological breech birth, including women who choose to birth without an epidural. To enable women to have a choice of pain relief for physiological birth without epidural, the hospital team are considering offering nitrous oxide (Entonox) for the first time. And for some of those attending this week’s training, our videos were their first exposure to women birthing in a kneeling position. One obstetrician suggested they could prepare for the change in breech practice by facilitating kneeling positions for cephalic births!
Dr Arianna Bonato, one of the external OB-GYNs attending the training, told me she feels that a breech birth is the most beautiful birth to see, because the physiology is so visible. I agree! This visibility makes possible learning about physiological birth in general within the microcosm of breech.
The way that a neurologically intact baby assists his own birth, the intuitive movements of a mother who feels safe and uninhibited, and the consequences of interventions in the mother-baby dance, to facilitate or disrupt, are all much more exposed. As Carmen Rubio reminded me, breech births demand calm wisdom in the birthing space like no other.
I have no doubt Hospital Sant Pau’s open-minded and forward-thinking approach will attract many more women to birth in this hospital, and that their midwifery unit will also thrive when it is opened. A blessing for the women of Barcelona. I look forward to staying in touch and learning from their experience of implementing these new practices!
Thank you to Consultant Obstetrician Ma Carmen Medina Mallen, and Maria Segura, for their work in organising the Breech Birth Network training this week. Hospital Sant Pau will be auditing their outcomes for term breech presentation over the next year, as part of our international evaluation of Physiological Breech Birth training.
Many thanks to midwives Carmen Rubio and Maria Segura for the translation of this blog into Catalan!
Aquesta setmana (21-22 de Març 2017), la Xarxa pel Part de Natges va estar a la bonica Ciutat de Barcelona, com a invitació dels ginecòlegs i llevadores de l’Hospital de Sant Pau. El nostre equip va créixer per l’ocasió! La llevadora Maria Segura va traduir totes les diapositives de la sessió al català i la llevadora Carmen Rubio, amb seu a Cardiff, va garantir que tothom pogués tenir l’oportunitat de rebre ajuda en la pràctica de les maniobres per assistir les dones que vulguin donar a llum en posicions verticals.
M’agrada estudiar i ensenyar el part de natges de manera fisiològica, sobretot, perquè quan els professionals aprenen el funcionament d’aquest, també ho fan sobre els fonaments de donar a llum. Encara que la seva aparent aplicació sigui per una petita proporció de la població, l’habilitat en l’art de facilitar els naixements de natges ressona a través de tota la pràctica professional, així com a la feina de col·laboració entre companys i al conjunt de les seves institucions.
La nostra experiència a Barcelona ho va deixar ben clar. L’Hospital està a un període de transició, intentant incrementar les xifres del part natural. El part de natges forma part d’això, però les llevadores, a més, estan treballant en la línia de crear la primera casa de naixements pública a Catalunya. L’Hospital ha establert recentment un nou protocol que permet als obstetres reconsiderar el part de natges de forma fisiològica, incloent-hi la voluntat de les dones que vulguin donar a llum sense epidural. A més, l’equip de l’Hospital està en vies d’introduir l’Òxid Nitrós (Entonox) per primera vegada, com un altre recurs d’analgèsia per les usuàries de part. Per alguns dels participants a la formació, va ser la seva primera vegada en veure, a través dels vídeos, a dones donant a llum en posició vertical. Una de les ginecòlogues va suggerir que es podrien preparar pel canvi en la pràctica de l’atenció al part facilitant més activament la posició vertical als naixements dels nadons que es troben en presentació cefàlica.
La Dr. Arianna B. una de les obstetres/ginecòlogues que va atendre la formació, em va dir que sentia que el naixement de natges és molt bonic d’observar, perquè en ell es pot veure clarament la fisiologia del part. I estic d’acord! Aquesta claredat és la que ha permès aprendre del part fisiològic en general des del microcosmos de les natges.
La forma en què un nadó neurològicament sa assisteix el seu propi naixement, els moviments que intuïtivament fa la mare quan se sent segura i desinhibida, i quines són les conseqüències de facilitar o interrompre la dansa entre mare i fill són molt clarament exposades. Com la Carmen Rubio em va recordar, el part de natges demana com cap altre, la saviesa calmada de l’espai en el qual es dóna a llum.
No tinc cap dubte que la ment oberta i de pensament avançat de l’Hospital de Sant Pau atraurà moltes més dones a aquest Hospital i que la seva Casa de Naixements serà també popular quan l’obrin. Una benedicció per les dones de Barcelona. Estic desitjant estar en contacte i aprendre de l’experiència en la implementació d’aquestes noves pràctiques.
Moltes gràcies als membres de l’equip obstètric, la Ma Carmen Medina Mallen i a Maria Segura, pel seu esforç organitzant la formació de la Xarxa pel Part de Natges. L’Hospital de Sant Pau auditarà durant l’any vinent els resultats dels parts en presentació de natges com a part de la nostra avaluació internacional respecte la formació del Naixement Fisiològic de Natges.
— Shawn, Carmen & Maria
To kick off the new year, Breech Birth Network are providing a study day in Norwich on 14 January 2017. If you’ve been wanting to encourage your obstetric colleagues or trainees to attend training, this will hit the spot. Our teaching team includes Dr Anke Reitter, FRCOG, Shawn Walker, RM, Victoria Cochrane, RM, and Mr Eamonn Breslin, MRCOG. Send your colleagues the link to our Eventbrite booking page, with a personal invitation! Or download a poster for your work environment.
This study day for obstetricians, midwives, paramedics and students will provide an engaging and interactive update on professional skills to facilitate physiological breech births, planned or unexpected. The study day would be especially useful for clinical skills teachers who want to include physiological breech methods in professional skills updates or student lessons, due to access to resources after the workshop. The focus is on collaborative, multi-professional working to improve the safety of vaginal breech birth using the skills of all maternity care professionals.
Training will include:
* A research update given by leading researchers in the field, including Dr Anke Reitter, FRCOG, IBCLC of Frankfurt
* Thorough theoretical and hands-on explanations of how breech babies journey through the maternal pelvis in a completely spontaneous birth (the breech mechanisms), enabling you to distinguish between normal progress and dystocia
* Hands-on simulation of complicated breech births and resolutions, using narratives and videos of real breech complications, to enable you to practice problem-solving in real time
* Models of breech care that work within modern maternity services
* An accompanying booklet containing handout versions of all of the slides and resources used in the training
* One year’s access to the on-line learning space following the training, to continue viewing and reflecting on birth videos (one per month) in a secure forum, and resources for sharing teaching with professionals in your practice community
* Lunch and refreshments
Registration begins at 8:30 for a 9:00 start
Hosted by the University of East Anglia University Midwifery Society. Profits from the study day will benefit the UEA Midwifery Society annual charity, the Orchid Project. See here for directions to the Edith Cavell Building, and to Norwich from further afield.
Feedback from study days in Christchurch & Auckland, October 2016:
My main concern was lack of training of staff leading them to believe that breech birth is an emergency. Our RMOs and MWs loved the day and I think feel more empowered. — SMO (Consultant Obstetrician, Senior Medical Officer)
Thank you so much, this has been the best study day ever! — Midwife
Information was clear and concise and well presented. Myths dispelled and physiological VBB and when to intervene very clearly explained. Methods to resolve when there are issues during delivery explained and demonstrated. Clear examples given with supporting video and photographs. Extremely valuable. — RMO (Registered Medical Officer)
Honest, real explanations. How to intervene in a timely manner as opposed to be hands off the breech. — Midwife
Thank you for a brilliant day of teaching and training. You covered a lot of material not taught as part of our training and it has been valuable. — RMO
Learning about manoeuvres to use in upright position, eg. shoulder press; visual components have been amazing, the broken down physiology of a breech birth. — Midwife
Dr Anke Reitter, FRCOG, IBCLC, is the lead Consultant Obstetrician and Fetal-Maternal Medicine Specialist at Krankenhaus Sachsenhausen, Frankfurt am Main. Although originally from Germany, she worked in India and the United States during her medical studies, and in England (including Liverpool) for 4 years during her obstetric training. After returning to Germany, she specialised in perinatal medicine. Prior to her move to Krankenhaus Sachsenhausen, where she initiated a new breech care pathway in a unit which had not supported breech births for years, Reitter practiced in the Obstetrics and Gynaecology department at the University Hospital Frankfurt. A large observational study of the hands/knees breech births in Frankfurt is due to be published soon in the FIGO journal. Her special interests lie in breech, multiple pregnancies, high risk pregnancies and prenatal ultrasound. She is an internationally known speaker, teacher and researcher in several areas, but especially breech birth.
Shawn Walker, RM, MA is a UK midwife and PhD candidate researcher who studies how professionals learn skills to safely facilitate breech births. Clinically, she has worked in all midwifery settings – labour wards, freestanding and alongside birth centres, and home births. She led the development of a breech clinic pathway at the James Paget University Hospital (2012-2014), where she worked as a Breech Specialist Midwife. Her research focus on breech birth is part of a wider interest in complex normality – working with obstetric colleagues to enable women at moderate and high risk to birth and bond physiologically where possible. She currently works as a bank midwife at the Norfolk & Norwich University Hospitals NHS Foundation Trust, in addition to periodic teaching, consultancy and breech support across the UK and internationally.
Victoria Cochrane, RM, MSc is the Consultant Midwife for Normality at the Chelsea and Westminster NHS Trust. RM, MSc, Supervisor of Midwives. The majority of her clinical career has been working in and developing caseload and continuity models for women and their families in the community. She is deeply passionate about working with colleagues to support women making pregnancy and birth choices that sit outside of routine guidance. In her current role she works to support normality for women in all aspects of pregnancy and birth. Breech presentation became a special interest in 2009 when her daughter spent a few weeks in that position at the end of pregnancy; it’s amazing what one can learn in a short space of time when faced with challenging choices. This led to carrying out a cross-site service evaluation of the management of undiagnosed breech for her MSc dissertation.
Reitter, A., Daviss, B.-A., Bisits, A., Schollenberger, A., Vogl, T., Herrmann, E., Louwen, F., Zangos, S., 2014. Does pregnancy and/or shifting positions create more room in a woman’s pelvis?Am. J. Obstet. Gynecol. 211, 662.e1-662.e9.
Walker, S., Scamell, M., Parker, P., 2016. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 34, 7–14.
Walker, S., Scamell, M., Parker, P., 2016. Principles of physiological breech birth practice: a Delphi study. Midwifery 43, 1-6. FREE DOWNLOAD until 13 December.
Walker S, Cochrane V (2015) Unexpected breech: what can midwives do? The Practising Midwife, 18(10): 26-29
Busy packing … leaving London for the US on Friday. Originally, I planned to attend the celebration of 20 Years of the Kelly Writers House and my college reunion at Penn, as well as the annual ACOG meeting where our film on upright breech birth is being shown, followed by a family wedding. But it turns out the first two conflicted, so instead I will be spending half of my holiday teaching breech in collaboration with other health professionals along the east coast of the US and Canada. With ‘renewed interest’ in vaginal breech birth from the ACOG, and Canadian SOGC guidelines fully supporting planned breech birth since 2009, the will to revive breech skills is in full swing in North America!
Some of the health professionals and birth activists collaborating to provide breech training in their communities include:
The training provided by Breech Birth Network is different from obstetric emergencies training because it is based on physiological birth principles, including the importance of maternal movement in facilitating the birth process. Decisions on when or whether to intervene in a breech birth are determined by careful observation of the unfolding mechanisms, recognition of deviations from the norm and strategies to restore the mechanism. These strategies include maternal movements, as well as hands-on help from birth professionals. In Breech Birth Network training, which follows recommendations outlined in primary research with experienced professionals, birth videos are central resources, enabling both experienced and inexperienced professionals to develop and expand their pattern recognition skills, even in communities where actual breech births remain a rarity. Therefore, the training is supplemented by secure access to the resources and videos, which cannot be downloaded, but can be used to refresh training by those who attend the hands-on workshops when preparing for a birth within their local teams — the Virtual Community of Practice (VCOP).
Thank you to the women, midwives and obstetricians who have made this possible in order to increase the safety of breech birth for others.
Training programmes are often evaluated according to Kirkpatrick’s hierarchy, which has 4 levels:
Thorough evaluations of breech birth training packages are lacking. Evaluating impact of training on maternal/neonatal outcomes is a longer-term project, easier to achieve when considering the effect of training within one site, rather than professionals working in many different contexts; we have plans to begin such a project later in the year. However, for this series of study days in North America, we are collecting data on how many breech births those participating have attended in the year before and after training (change in behaviour), as well as changes in confidence levels before and after training (change in learning).
Those attending these training days include obstetricians, CNMs, CPMs, students, and birth activists keen to support cultural change in their communities. The results of the evaluation will help us to determine whether providing breech birth training based on conceptual understanding of physiological principles, within a community of practice/network learning model, will increase women’s access to the option of vaginal breech birth by increasing provider confidence and skills to provide this service.
The evaluation data will also contribute to answering two fundamental questions, which will require on-going research in the future:
Thank you to all the health professionals participating in this training and evaluation. I am looking forward to meeting you and learning from your communities!
P.S. Of course, we aren’t the only source of physiological breech birth training. Others include:
We advocate that all professionals including breech within their sphere of practice access breech training from multiple providers, consider the underlying principles and how they fit with your own understanding and experiences of birth, and maintain an open mind.
Over and over again, in my research and in personal conversations, I hear how important videos are to health professionals who are self-educating themselves about breech birth. I am still exploring the role of video as a learning tool, but they seem to assist professionals to develop pattern recognition abilities, and enable discussions about clinical decision-making. By watching and talking through what happens in birth videos, these skills can be practiced before they are required in a real-life context.
Here is a list of publicly available on-line videos for health professionals to watch when preparing to attend a breech birth, or to periodically update. Some of them may be close to your idea of ‘ideal,’ and some of them may present a different perspective, or an opportunity for discussion. All of them offer learning opportunity.
You can link to the original posting of the YouTube videos by clicking “View on YouTube” in the bottom right hand corner of the viewer.
Nascimento Mariana – with Dr Priscila Ribeiro Huguet
Frank Breech Home Birth – Spinning Babies Blog, with Gail Tully
Thank you to the very brave and generous mothers, fathers, midwives and doctors who have shared these videos so that others can learn about breech birth.
If you have posted a video of your breech birth, and would like to share that with others, please do include a link in the comments below.