Sunday, December 18, 2016

Shawn Walker: Supporting breech birth within a paradigm of complex normality

First Amsterdam Breech Conference, Day 2
Shawn Walker, RM, MA, PhD cand.
Developing health professionals to support breech birth 
within a paradigm of complex normality

Shawn Walker is a registered midwife in the UK and a PhD candidate. She worked as a Breech Specialist Midwife in a NHS breech clinic and has attended births in homes, birth centers, and hospitals. Her PhD research focuses on upright breech birth.

Shawn opened her presentation with an extended analogy:
       In a parallel universe, imagine that 96% of babies are born bottom-first, and everyone knows all the variations of breech. Occasionally there are tricky situations and that’s where consultant OBs jump in.
       But then there are these 4% of babies presenting head-first that cause all sorts of trouble. Occasionally their heads come out and their shoulders don’t follow and panic ensures. And then someone gets the idea of having a term vertex trial, and it turns out the cesarean is safer than vertex birth. Gradually—because brachial plexus injury for shoulder dystocia is 1/20—cesarean becomes the standard of care for head-down babies.
       The occasional radical midwife makes trouble, suggesting that we go back to basics and look at the physiology of what happens when women direct their own births. Nope, OBs suggest it’s an obstetric issue; midwives shouldn’t be involved since they can’t provide the complete package of care.
       And then a very powerful and well-connected OB was having a telephone conversation and he saw a picture of someone doing axial traction to deliver the shoulders. He thought, let’s put women with vertex babies in upright positions where they can move and see what happens. And then another troublemaker in Canada proposed that midwives should be involved in vertex births because they have smaller hands and don’t even need to cut episiotomies. And so began the Small Hands Revolution!
       And then some researchers presented their data from all around the world insisting the data is clear that vertex is not as safe, but we must still have shared decision-making. And for that choice to be available, we must have access to the safest possible care. But we still feel vulnerable—how can we make it safer? Then a visionary said, “Look, it’s the 21st century. Birth is safer than it’s ever been—why can’t we do the same for vertex birth? How can we help each other feel less vulnerable?”

(If you hadn't noticed it already, Shawn just summarized Day 1 of the Amsterdam Breech Conference!)

Shawn then argued that there’s a paradigm shift going on to seeing breech as a complex normality, rather than an abnormality.

What is required to become competent in breech?
Shawn's recent article, Standards for maternity care professionals attending planned upright breech births (Midwifery Mar 2016) "establishe[d] a consensus of opinion on standards of competence for professionals attending upright breech births." The key elements are:
1. Hands-on simulation (skills and drills)
2. Regular opportunities to discuss with peers and mentors
3. Watching breech birth videos
4. Theoretical instruction in anatomy, physiology, mechanisms, and maneuvers
5. Mentorship and supervision in clinical settings
We can use videos of breech births to enable pattern recognition. What does that mean? When you attend a high number of births, you begin to recognize certain patterns. Shawn showed two side-by-side births. Both had good outcomes, with one being completely normal and the other right on the border of needing intervention.

We need to know what normal looks like (sternal crease or “cleavage," baby's body facing straight) versus what needs help (baby's body facing sideways).

Videos are great for practicing clinical decision-making. Shawn likes to play “save the baby.” Colleagues chime in while watching videos and say what should be done to help in a tricky situation. When you see signs of trouble--because you already know the signs and patterns of normal--you can then confidently step in and help a baby that can’t birth by itself.

Shawn also does Breech Study Days all around the world. Core elements of her physiological breech birth training include
1. Research updates—counselling is a skill
2. Teaching what is “normal for breech:” mechanisms, other features
3. Complicated Breech Births: skills and maneuvers
4. Simulations and case scenarios

When all is well, respect the mechanism

When all is not well, restore the mechanism

Shawn's online Moodle space facilitates great discussions among care providers all around the world and lets members share and compare videos. A new video is released each month to simulate the process of attending a breech birth regularly. Study Day participants get 1 year free access.

Shawn has also been evaluating her teaching, especially levels of confidence in her trainees before & after the training. She has found significantly increased confidence levels post-training.

We desperately need research evaluating real outcomes after breech skills training, not just confidence levels. She noted that PROMPT excludes outcomes of vaginal breech babies in their evaluation. Shawn will be evaluating this aspect from her recent training sessions in North America, doing a 1-year followup to see if there has been a change in behavior and outcomes, in addition to confidence levels.

Shawn also noted that obstetric emergency breech training does not lead to an increase in rates of vaginal breech births; it actually makes the rate go down. Can we make the rate of vaginal breech births go up? She’s also doing a visit to Auckland in the fall and collecting before/after data. She requested that if you’re doing breech teaching, please collaborate with hospitals to gather before & after data.

The most interesting question, Shawn remarked, is, Can we make breech birth safer?


Q from Andrew Bisits: Regarding the emphasis on mechanics, clearly I agree . It’s doable because we do and can understand the mechanics. However, the other part of making it safer is the oxygenation issue, particularly in the 2nd stage. There are unknowns in this aspect in how a baby copes. What are your thoughts about that area?
A: Regarding oxygenation and how we teach people how to evaluation fetal well being in 2nd stage and make decisions: when you’re a HB midwife and you start out, you have a higher transfer rate a the beginning. I maintain that 3-5 minutes from the umbilicus to birth is a great starting place (but it wasn’t approved by my consensus panel) because when you’re an expert, you have more intuitive knowledge and thus more time to play with. Novices need to be taught good methods: not to intervene too soon, but to be assertive with time if there isn’t clear evidence of good fetal well-being.

Q from a Dutch OB: It's really good for us to hear about your parallel universe and it made everything so clear at once. Two things about the videos: 1) cleavage: if you see the baby’s chest with a crease, that means the arms are close by and you just need to wait for another contraction. If you see a flat chest, you need to help the arms. 2) Meconium: not a sign of fetal distress in a breech. Tell your nurses and other staff there for the first time so they don’t worry about it. Be happy about the meconium—it’s a great sign in a breech birth.
A: Yes, in a full-day training course, that’s absolutely what we go over. Also tell your nurses, 2nd midwife, etc, that fresh mec is different from mec stained waters. Don’t document fresh mec as mec stained waters.

Q from Anke Reitter: Even if the baby seems to do all the right things, babies that have been compromised in 2nd stage will not help with the process and will look different (no tone, etc.). They need active hands-on. It’s like doing a cesarean on a baby with little or no tone.

Q: If you talk about making birth safer and about counseling, how do you involve the mother to make birth safer because she’s birthing her baby? How in your experience does it work better if the mother is fully involved?
A: You do have an obligation to share these numbers with them, though as Andrew Bisits remarked it can be complicated. As Floortje Vlemmix said, she asks women “What are you thinking about?” or “What do you know?” I also use videos to show women so they have an idea of how normal breech works. I also talk about what I'd do in complications and what I might say and what it means—so the woman understands beforehand.

Q: Do you find that if women have more confidence, it actually works better? Does her instinctive behavior help?
A: The movement to create breech specialist clinics is very very good. I will keep promoting that. I was a breech specialist midwife and I counseled everyone with a breech presentation. The women who’d come through my clinic chose VBB at a same rate as Dutch data (around 30 is %). Those women had easier births than women who came from outside with conflicted situations, who had to fight for their breech births. Sometimes they didn't know when to stop fighting. We should not make women fight for what they want.

Q from a Dutch obstetric resident: After hearing your alternate paradigm universe [in which breech is normal and head-down is uncommon], we are feeling so convinced to do it on all fours. Then we go out in our practice and we have colleagues who haven’t been to this conference. Should we try to convince our colleagues? No, instead we should gather together and carefully evaluate the short and long-term consequences of what we’re doing.
A: Definitely. To a certain extent, these techniques have been well-evaluated (for example, with Frank Louwen's study). Also, you cannot evaluate something until someone becomes competent in it--one of the problems with the TBT. Until you actually practice it, you cannot evaluate it properly. There’s a certain amount of latitude that experienced professionals have to say “This makes sense and I would like to try it.” You should certainly come together to help other people make those transitions, to help them get over the learning curve.

Q: May I add something: After this conference, we agree that the Netherlands is a small land. We can easily start here in Amsterdam. Our hospitals are on board to work together to help women to find the right place and to have those options. It’s easy to evaluate because you can do the births together and film them. We will do that here.


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