2016 Amsterdam Breech Conference
June 30-July 1, 2016

Shawn Walker, RM, MA, PhD: 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:

Shawn summarized Day 1 of the Amsterdam Breech Conference via storytelling, imagining an alternative universe where 97% of babies were breech and everyone was so scared of cephalic babies that they were advocating universal cesarean section. 

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:

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

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%). 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.