Tag Archives: Training

Becoming a Breech Specialist and Setting up a Breech Service within the NHS

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.”

And

“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.

Teaching physiological breech birth at City, University of London

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, 2017Walker et al, 2017Walker 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:

Breech service referral process at St George’s University Hospital NHS Foundation Trust

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.

Breech information leaflet developed by the Breech Birth Network, CIC

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.

Emma

Stockholm and the breech

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

It was exciting to see a ‘Breech Team‘ service working so well in the largest maternity hospital in Stockholm. The team are able to take referrals for women pregnant with a breech-presenting baby at term who wish to give birth at SÖS. They can also provide training for other teams in Sweden who wish to improve the safety and delivery of their own services, using their own resources and presentation materials provided by the Breech Birth Network.

To ask about referral or training, please contact Julia and Tove using the form below.

Typical Swedish post-birth meal — a step up from British tea and toast!

Each family places a pin in the board to celebrate their birth as she leaves SÖS

Busy hospital!

For more information about training outside of Sweden, please see our Booking a Study Day page.

For information about training or referrals for a vaginal breech birth in Sweden, contact Julia and Tove:

Breech Training in Quebec

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:

Teaching Breech in Inukjuak

 “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.

Teaching Breech in Inukjuak

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)

Please visit: Regroupment les sages – femmes du Quebec

 


From Shawn:

A picture of my lovely Innukshuk, given to me by Kay Guruswami of Kensington Midwives in Ontario, as a symbol of what we are trying to do together: lead the way forward for breech. Thanks Kay  ❤️

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

Breech in Belfast

Consultant Obstetricians Niamh McCabe and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson

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

Cloth Pelvic Model; or

Female Pelvis Model

Final announcement: Blogging has resumed because … I submitted my PhD a couple weeks ago! Hurrah!

Shawn

Krankenhaus Sachsenhausen is also on Facebook!

Visca les natges! Barcelona breech training

(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.

“Give it a wiggle” / “Donar una sacsejada” !

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.

— Shawn

Elevate & Rotate from Shawn Walker on Vimeo.


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.

Hospital Sant Pau

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