Down in the Trumps

I recently read that it really does seem that David Bowie kept the world in order; proof is the rather crazy world events that have occurred this year since his very sad demise.  It has been a roller coaster year and its not quite over yet…

The certainties are a lot less certain following Brexit and Trump or perhaps the illusion of certainty is being uncovered. In my most optimistic moments (there has only been one and it was after a shandy) I think perhaps the changes afoot will bring opportunities, improvements and a fresh approach to long standing problems. But then I look to those who hold power and fear that the marginalised will become more silenced and I reach for the chocolate cake and worry.

What will all this mean for maternity care?  The impact of these world events ripple all over and impact on relationships, behaviours, tolerances and social norms. The more inclusive, socially aware and diverse societies tend to develop quicker and stronger than those which are narrow minded, punitive and reduce the rights of those who are not represented in positions of power.  Are we growing as a nation (or world) or have we just shut the doors and built the walls that will restrict and limit our growth and development?

Will maternity services become more restricted by lack of funds and staffing pressure to meet the needs of pregnant women and will there be less tolerance for those who want something different from the often limited pathways of care offered?  In my work life journey I have heard some terrible birth stories of women feeling isolated, ridiculed and made to feel unsafe for wanting to make their own decisions at a time where they are most vulnerable; heavily pregnant or in labour.  I have also heard warming stories of those same women being supported, guided and respected for making their own choices.  We need less of the first and the norm of the second.

My worry over events of this year is that the ripples will mean women will be heard less, there will be less diversity and growth and the options will reduce.  But we must not retreat to cake, we must put the fork down and speak out!

There are lovely things happening as well that balances my cake wobbles. It is wonderful that the fabulous Neighbourhood Midwives have signed their first NHS contract with Waltham Forest CCG, a great collective working that will surely strengthen maternity services as well as being a great option for women in that pocket of the world.  Congratulations to them!

A few weeks ago I ran a breech skills workshop for student midwives who were inspirational in their commitment and enthusiasm to learn and shape their own midwifery journey and that of the future maternity services.  So warmed by the next generation of birth workers I committed then and there to do as many breech skills workshops as possible, for cost, to do my bit for increasing birth diversity, ensuring options remain for those who tread a different path and support staff who need just confidence in their own breech knowledge and skills. So if you fancy a fab breech skills workshop in your area give me a shout – I may even bring my chocolate cake!



18 things I have learnt in 18 years as a midwife

I have learnt a thousand and one things from birth, birthing women and birth workers but had a stab at my 18 favourites to share with you:

1. Birth is extraordinarily amazing; it still makes me go WOW
2. You learn more from the births you attend than any text book or blog account
3. Never reach too far into a birthing pool; there is a point where you will fall in head first
4. Birth positions should suit birthing women; the often portrayed birth image of the passive women lying on her back, pushing her baby uphill as the doctor/midwife heroically directs and delivers still makes me livid
5. You never sleep as well when you are on call for a birth (and you sound like a bleary dolt when you answer the phone at 3am)
6. Institutional birth language is unacceptable – There are no ‘incompetent cervixes’, only incompetent descriptors. There are no ‘failure to progress’ labours, only a failure in care, support or ability to meet an imposed deadline.
7. Beware the colleague who presents their opinion as fact; the more confidently they assert their opinion the more suspicious you should be. Question everything.
8. You can never have enough towels at a birth, they can be used in innovative and interesting ways
9. If in doubt go with common sense. It makes sense to not clamp or cut a cord before it has stopped pulsating, it makes sense to keep mum and baby skin to skin, it makes sense to be mobile and upright during labour, it makes sense to eat and drink when you need to – generally it makes sense not to interfere unless there is a need.
10. Vernix is the best moisturiser in the world – don’t wash it off but rub it in!
11. We need to stop being so cervix obsessed – they are beautiful but they don’t read the book on how fast they need to open to keep health professionals happy. Vaginal examinations should be an exception not the routine. Observe, be quiet and be patient.
12. Watch where you stand when a women is labouring and her waters are yet to break (and always keep an extra top in your bag)
13. Never be in awe of the (so called) ‘experts’, only of birth and birthing women.
14. Your sense of smell is a tool you will use more than you think; a midwife can identify liquor over urine at 10 paces and blindfolded
15. ‘It’s just the way we do things here’ is the worst (and most dangerous) excuse for poor behaviours and questionable practice. Don’t follow the crowd – be a goat not a sheep.
16. We need to stop fragmenting birth; I look forward to the day when breech birth is just birth; VBAC women are just birthing women and waterbirth is when you get wet.
17. Scrubs are the clothing of surgery, emergencies and high drama TV. They may be more comfortable for staff in hot busy labour wards but I believe they send hugely negative subconscious messages to women hoping to avoid all of the above (especially the high drama TV)
18. Everything is possible. Nothing is impossible


Overdue Breech

I was reminded via twitter this week of my clumsy attempt at comedy when speaking at the fabulous CCSU MidSoc conference earlier this year: “I am, like many others, a little frustrated at how long we have been waiting for the RCOG to revise and update its guidelines; they are so overdue if they were a baby they would have been born by emergency caesarean section by now” (don’t worry I’m keeping the day job…).
The current RCOG breech guidelines were published in 2006, a whole 10 years ago. Only 1 other green top guideline is older (Tubal Pregnancy, 2004) so why is the breech guideline taking so long when there have been several good pieces of research and mounting evidence that a change of guidance is required?
We all know that change in healthcare can be really slow; like a massive ship trying to change course with a reluctant captain who rather likes the view as it is. But there are rather telling examples where change has been rapid. When the Term Breech Trial (Hannah et al, 2000) published their controversial results of their breech research in 2000 the number of vaginal breech births declined dramatically across the world. In the Netherlands, caesarean section for breech rose from 50% to 80% within 2 months of the publication of the research (Reitberg et al, 2005) and it has been said that no other research has impacted an area of clinical practice in such a short period of time.
It appears that the good captain had already plotted the course and was just waiting for the green light to turn hard right, full steam ahead. My obstetric colleague whispered that it was a relief that they would not be called for the odd ‘difficult’ vaginal breech in the middle of the night again; much easier the planned caesarean at 10am.
The move to surgical delivery for all breech babies at the turn of this century could not be more neatly presented as an example medicalisation of childbirth. Breech was redefined in a moment as the abnormal, dangerous and in need of obstetric intervention and rescue. And women’s birth choices were effectively removed.
The ship needs steering back on course; vaginal breech is a safe option for some women according to the current evidence, but I fear there is some reluctance in some quarters. Medicine, who advocates the authority of research to guide clinical practice, appears distracted and unconvinced when presented with current research that supports vaginal breech birth as an option. Local breech clinical guidelines reviewed and updated with the most up to date evidence, are not signed off as they don’t align with the 10year old breech RCOG guidelines. And I continue to hear that women are still being told they are ‘not allowed’ a vaginal breech birth or that there ‘aren’t staff with the skills’ to support their choices.

In this age of medical dominance the RCOG is a powerful and influential body which can make a difference. The draft RCOG breech guidelines I was able to review and comment on earlier this year were a huge improvement and will be a game changer for women and advocates for women’s birth choice (surely this is everyone??).
So I look forward in anticipation to these overdue breech guidelines. I know there are stirrings and that labour is imminent; not normally one to interfere, in this case I would offer these breech guidelines a stretch and sweep to move it along a little swifter – just give me a call.


Breech: Ordering off the menu

36164523 - new born baby feet. hand of the mother holding the sleeping baby boy little foot up.

I used to not be very adventurous with food. I wasn’t a fussy eater as such I just hadn’t been exposed to different types of food when I was young so I was quite cautious. I was gently introduced to the world of flavour through a korma curry when I was 20, and now elbow people out the way to the hot and spicy counter and love trying new things.  I have even had a go at ordering off the menu, either driven my taste buds or that nothing on the menu was my thing. And mostly this has been a good experience, with me, the customer humoured and accommodated. Occasionally there is a stony ‘no’ (it’s just not possible in pre-cooked greasy burger joints) and on the very rare occasion I was in fear of being ejected from the premises for even daring to imply the menu was inadequate (a rather snotty pretentious restaurant in my view).

Is modern birth services options like a menu? Who develops the menu and how is it presented? How easy is it to order off the menu and what is that experience like?

Practically the menu is mainly the clinical guidelines that help clinical staff decide the best thing to do based on the evidence available.  My experience is that whilst some commonalities can be found, local clinical guidelines vary due the rest of the stuff that has a significant but rarely acknowledged impact on what ends up on the menu. Stuff like personal views, experiences, beliefs and ‘how we do things round here’ impact on what is in a clinical guideline.  I was once, some years ago,  in  a team who were updating breech clinical guidelines at a maternity unit when I was told to tone it down (I think I was including the option of active, upright breech birth section) or I would never get it past the obstetricians. This was despite my arguments that giving being required to give birth on your back in stirrups as per the current guidelines had no research basis at all. My text remained in (stubborn me).

I am aware that in some maternity services the users of that service, the women and their families, have no input into the development of clinical guidelines that directly affect them; the menu is off limits in terms of deciding what’s on offer.  Perhaps a chef would argue that only she/he, the expert, would know what food is best to serve. But of course we are not talking about food, we are talking about birth and who is the expert at birth (my vote is birthing women).

But what if nothing on the menu takes your fancy. Hold the beef and potato stew, I’m hankering after roasted snails cooked with pineapple and paprika today kinda thing. Well, from listening to many women’s breech birth stories, there are mixed responses but a common one is of a sad battle to get their pineappley snails/not on the menu birth choices. Some women are given the ‘no can do’ response (think greasy burger joint) and others are made to feel very alienated, ostracised and even stupid from even asking for their desired snails (think snotty restaurant). Some even leave the entire food joint and go and find a nice chef (in another maternity unit or independent midwife) who will listen, respect and facilitate their choices.

Ordering off the menu is hard work, it can be stressful and women share that it harms their relationships with care providers who won’t consider their needs. Perhaps then we need to look who and how the menu is developed. Including the people who use the service in clinical guideline development is a no-brainer, it is empowering and enabling and forms partnerships of trust and respect. Maternity Service Liaison committees do sterling work in this area. Involving service users in research and building and sharing of knowledge around birth is also common sense. What’s important to those giving birth should be the central starting point for developments and innovations. Ordering from the birth menu that you shaped is much easier than choosing off the chef’s version of culinary heaven.

And finally we need to consider if we need a different type of menu; is there a new way of doing things out there? The maternity services review certainly thinks it’s time for a change. The proposed personal budgets will certainly go some way to empowering women in their birth choice and feel more like the buffet style approach to birth. They offer you to take a plate and fork and add the tasty morsels you desire to build a meal that really tingles your taste buds; your own unique birth journey how and where you want it.

Pineappley snails are not for everyone, but nor is beef stew. Let’s change the birth menu and the mindset of choice.


Giving birth to stars

After having a catch up with a lawyer friend last week I reflected on the desirability of certainty, and its antithesis, the messy reality of uncertainty.  The law, my friend tells me, provides considerable certainty, especially so when considering principles known as the ‘black letter law’. This impressive term is defined as:

‘a principle of law so notorious and entrenched that it is commonly known and rarely disputed’ (Duhaime’s law dictionary)

This is when a belief, view or understanding becomes so resolutely agreed by those who hold the power, in this case judges, it becomes indisputable ‘fact’ and ‘is no longer subject to reasonable dispute’.  Interesting stuff. It must be really helpful to have these entrenched beliefs to guide you as you confidently go through life; they are a given, an absolute, a certainty on which you can pin your colours and not worry again.

This brings me to some thoughts; how attractive certainty is, how you don’t need to worry if you are certain so it makes things a little bit easier. And how fragile certainty is, based on the collective views of others, often those in power, but passed to us as indisputable facts. And how birth can be such an uncertain time in a generally uncertain life.

In midwifery uncertainty is acknowledged and accepted as part of birth. As a midwife I learnt to be patient, to observe and prepare for any eventuality. The many nights waiting to be called for homebirths over the years was a warm reminder of how beautifully unplanned nature was. I learnt from women and their unique and individual birth journeys, spotting the common threads between them that help you to know the few occasions when women or babies needed help.

My experiences of discussing certainty and uncertainty with my obstetric colleagues has been fascinating.  A good example is induction of labour when pregnancy is considered overdue (usually around 41 weeks gestation). I chatted with a doctor a few months ago who was convinced that no women would choose to continue the burden and uncertainty of pregnancy over ‘getting on with it’ induction, with the added benefits of being guaranteed a baby in arms by dinner time the next day-ish (very ish).

But despite the ongoing debate on what really is ‘overdue’ in pregnancy terms and ongoing concerns over the risks / benefits of induction this intervention has been widely adopted, leading to nearly a quarter of all pregnancies being induced (see Rebecca Dekker’s excellent summary here). But perhaps the attraction of induction is the attraction of certainty, for many it must be good to know they are on the final run and there is certainty in being told you will likely be back home with a baby in a day or two or three or four.  It certainly helps with your Facebook status and stops those pesky enquiring phone calls from friends and family.

But what would happen if we turned this on its head and dealt with uncertainty in a different way. Uncertainty can bring stress and unhappiness but can also be the way that amazing things can happen, where we are more than we ever thought we could be.  Women who I have talked with about their breech birth experiences described periods of intense uncertainty where they didn’t know what to do, they felt stressed and often fearful, exacerbated by the fears of others.  Women described navigating this uncertainty finding their way and seeking alternatives and people who would listen and support them.  But they also described the moments where they made their decision on how and where to birth, drawing deep within themselves and from others to reach a place of self-certainty about what to do next.  These women described how they drew strength and confidence in themselves and their babies from their birth experiences, though many expressed how they wished they hadn’t needed to battle so much to have their decisions respected.

Perhaps this tells us that uncertainty allows a time for looking outside the box, ordering off the menu. It also suggests that certainty is very personal, rather than an entrenched notion or concept that is applied to (imposed on) all similar situations and populations. Developing self-certainty can be empowering as it develops from an individual’s own ideals, beliefs and situations, rather than those of others.

This doesn’t just apply to breech birth of course; women are faced with many situations within their pregnancy and beyond into motherhood where uncertainty and certainty go hand in hand.  Certainty through care pathways doesn’t always provide definitive answers or guaranteed outcomes. Uncertainty is not always a negative, but perhaps also an opportunity for liberation and freedom of choice.

‘You must have chaos in your heart to give birth to stars.’  Nietzsche

Whilst we may not desire chaos, uncertainty may provide opportunities to explore, to consider the alternatives and perhaps, even, to give birth to stars



Twitter: @JenD2605

Birth Rights & Choices; the Hot Breech Birth

Birth Rights & Choices; the Hot Breech Birth

After a swealtering week in the UK the hot topics in maternity care have been on my mind. There is so much in the headlines with the new ways of working following the State of the Maternity Services report. There is also excting work from  Rebecca Schiller whose book Why Human Rights in Childbirth Matter coming out shortly highlighting the essential premise that all women are entitled to respectful maternity care that protects their human rights and birth rights.

Breech, that only touches a small proportion of women and pops up occasionally for birth workers, seems a very insignificant deal alongside these big hitters.  And yet for those women who it does affect it is the biggest deal.  Women that I talk to about their experiences of breech say that finding out their baby was breech was a huge thing.  For some it was devastating, taking all their dreams of the birth they had planned and wanted, for others it was the start of a battle for their right to choose their birth preference and for others it was overwhelming fear of breech and what was to come.

I read and hear about women who say they ‘had to have’ a casarean because their baby was breech and were not offered a choice to have a vaginal birth. I have talked to some health professionals who admit to putting things in a way that means women usually end up ‘choosing’ a casarean section (see Andrew Kotaska’s article on coersion around councelling for breech birth).  I have listened to women who tell me they were told they were ‘stupid’ for even considering a vaginal breech birth and how isolated they felt when making their decisions. It was one of the reasons I developed the breech birthing website, to offer a source of information and support for women’s birth rights and choices.

All of these are examples of the violation of the Human Rights Act, Article 8: Failure to provide sufficient, objective and unbiased information for a woman to make an informed choice. Its worth checking in with the Human Rights Act and Birthrights excellent website: to know the law of the land.

Breech, like all births needs respecting as does each woman (and their families) who carries a breech baby.  Each situation needs to be considered in terms of the safest thing to do for both mum and baby but with HONESTY about what we know, how we know it and most importantly what we DON’T know – and we still dont know a lot about breech presentation and breech birth (see the research section on the website).  The law needs to be followed, professional regulations need to be adhered to (NMC Code of Conduct, GMC Duties of a Doctor) but  simply we need to apply the family rule. People need to treat people how they would like their own family to be treated, with care and compassion.

Breech is a hot topic.  Breech is a human rights issue.  Breech is a birth rights issue. The minimum required is to ensure women with breech babies have the freedom to make choices, lets make that happen today!


Breech Skills Workshops – low cost high value

As a commitment to reinvigorating confidence and real options for breech I am currently offering workshops for ‘expenses only’ cost. This means if you can get a group of students or qualified health professionals together, ideally between 8-15 people, then I will travel to you and facilitate a 4/5hr breech skills workshop.

Here is what’s I can offer:

  • I have been a midwife for nearly 20yrs and have worked in all types of maternity care settings and home
  • I am a qualified teacher and for over 10yrs have taught breech birth skills, with upright breech skills being the norm,  to midwives, obstetricians and students
  • I have clinical experience of supporting breech births,  both upright and other positions. Most breech births I have attended have been straightforward but a few have needed help
  • I have completed 2 research studies on breech, and finished my PhD on the experience of breech birth in 2015.
  • I learn from women and other birth workers continually; experiences and stories are strong and important part of birth skills knowledge

I believe learning should be accessible and practical and teaching clear, memorable (in a good way!) and honest.

I believe breech skills are like all birth skills; they have fundamentals in basic physiology and anatomy,  recognising when some births need help and having a toolkit of things to provide that assistance keeps mums and babies as safe as possible.

I believe breech birth does not need to be high-risk obstetric-led but is a birth that does best with teamwork, support and respect.

Sounds good?

Contact me and we can have a chat:

See what other people say about the workshop here