Vaginal Breech Proficiency by Breech Without Borders

Vaginal Breech Proficiency is an online, slightly abbreviated version of the 2-day vaginal breech workshops offered by Breech Without Borders. The workshop is co-taught by an obstetrician with experience in both home and hospital births and in both low- and high-resource settings (David Hayes, MD) and a breech researcher (Rixa Freeze, PhD). This course first covers the evidence on term breech in both hospital and community settings over the past two decades. Next, the instructors reviews the history and development of obstetric breech maneuvers over the past four centuries. With this background information, the instructors explain the mechanics of physiological breech birth as well as maneuvers developed specifically for upright breech births. Next, they dive into clinical aspects of vaginal breech birth: what normal and abnormal breech births look like (illustrated with videos of breech births attended by Dr. Hayes) as well as maneuvers to resolve obstructed breech birth in both upright and supine positions. The course then presents information about the risks and outcomes of various breech presentations (frank, complete, footling, etc.). And finally, Dr. Hayes and Dr. Freeze bring all of this information together in simulation sessions using Sophie and Her Mum obstetric simulators. They demonstrate all of the maneuvers discussed during the workshop, then apply the maneuvers to simulated clinical scenarios.

$225.00 USD
Total CE Hours: 13.00   Access Time: 8 Weeks  
Lectures in this bundle (6):
Durations: 60 mins
Session 1: Evidence on Term Breech Since the 2000 Term Breech Trial

Dr. Rixa Freeze has a PhD in American Studies from the University of Iowa. Her doctoral studies focused on the history of healthcare and medicine with specialization in pregnancy, childbirth, and maternity care. Her dissertation examined why women in North America choose unassisted home births. She worked as a visiting assistant professor for 9 years at Wabash college. She has published two articles about home birth: “Staying Home to Give Birth: Why Women in the United States Choose Home Birth” (JMWH 2009) and “Attitudes Towards Home Birth in the USA” (Expert Review of Obstetrics & Gynecology 2010). She recently published the article “Breech birth at home: Outcomes of 60 breech and 109 cephalic planned home and birth center births” with BMC Pregnancy & Childbirth. In 2019 she published an article about outcomes of breech at home, birth centers, and hospitals (Midwifery Today) and a book chapter “Freebirth in the United States” in the 2020 book Canary in the Coal Mine. She is the founder and president of Breech Without Borders, a 501(c)3 nonprofit dedicated to breech training, education, and advocacy.

At the end of the session the participant should be able to:

Objective 1: Describe the conclusions of the 2000 Term Breech Trial.

Objective 2: Identify the main flaws of the 2000 Term Breech Trial.

Objective 3: List where the overall evidence falls for planned vaginal breech versus planned cesarean section for breech birth with regards to:
• Neonatal mortality.
• Short-term neonatal morbidity.
• Long-term childhood outcomes.
• Short-term maternal outcomes.
• Long-term maternal outcomes.
• Identify reasons for continuing to offer vaginal breech birth.

Abstract:

This presentation explores emerging evidence on term breech birth. Studies on both short-and long-term maternal outcomes tend to favor planned vaginal birth over planned cesarean section. Because of the long-term benefits of vaginal birth to both mother and baby, I argue that providers and clinics should prioritize vaginal breech training, implement policies to support breech providers, and offer access to vaginal breech birth or referrals to breech specialty centers. Unlike a policy of universal cesarean, this proposed approach also supports maternal autonomy and protects health providers from violating women’s legal and ethical rights to informed consent and refusal.

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Durations: 60 mins
Session 2: Outcomes of community breech birth

Dr. Rixa Freeze has a PhD in American Studies from the University of Iowa. Her doctoral studies focused on the history of healthcare and medicine with specialization in pregnancy, childbirth, and maternity care. Her dissertation examined why women in North America choose unassisted home births. She worked as a visiting assistant professor for 9 years at Wabash college. She has published two articles about home birth: “Staying Home to Give Birth: Why Women in the United States Choose Home Birth” (JMWH 2009) and “Attitudes Towards Home Birth in the USA” (Expert Review of Obstetrics & Gynecology 2010). She recently published the article “Breech birth at home: Outcomes of 60 breech and 109 cephalic planned home and birth center births” with BMC Pregnancy & Childbirth. In 2019 she published an article about outcomes of breech at home, birth centers, and hospitals (Midwifery Today) and a book chapter “Freebirth in the United States” in the 2020 book Canary in the Coal Mine. She is the founder and president of Breech Without Borders, a 501(c)3 nonprofit dedicated to breech training, education, and advocacy.

At the end of the session the participant should be able to:

Objective 1: List the existing sources for outcomes of out-of-hospital breech birth.
Objective 2: Identify weaknesses and gaps in the existing literature on out-of-hospital breech birth.
Objective 3: Describe outcomes of planned home breech birth when attended by an experienced provider with clear protocols.
Objective 4: Create a data collection plan for their own midwifery/obstetric practice, if applicable

Abstract:

This lecture presents the existing literature on outcomes of breech birth at home and in birth centers. I give suggestions for data collection for out-of-hospital births so that we can, in the future, add more evidence to the very small number of studies examining outcomes of breech births at home or in birth centers.

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Durations: 180 mins
Session 3: Breech maneuvers from 1609 to the present

Dr. Rixa Freeze has a PhD in American Studies from the University of Iowa. Her doctoral studies focused on the history of healthcare and medicine with specialization in pregnancy, childbirth, and maternity care. Her dissertation examined why women in North America choose unassisted home births. She worked as a visiting assistant professor for 9 years at Wabash college. She has published two articles about home birth: “Staying Home to Give Birth: Why Women in the United States Choose Home Birth” (JMWH 2009) and “Attitudes Towards Home Birth in the USA” (Expert Review of Obstetrics & Gynecology 2010). She recently published the article “Breech birth at home: Outcomes of 60 breech and 109 cephalic planned home and birth center births” with BMC Pregnancy & Childbirth. In 2019 she published an article about outcomes of breech at home, birth centers, and hospitals (Midwifery Today) and a book chapter “Freebirth in the United States” in the 2020 book Canary in the Coal Mine. She is the founder and president of Breech Without Borders, a 501(c)3 nonprofit dedicated to breech training, education, and advocacy.

At the end of the session the participant should be able to:

Objective 1: Identify the main types of obstetric maneuvers for vaginal breech birth developed over the past 4 centuries.
Objective 2: List the 10 mechanisms of spontaneous upright breech birth.
Objective 3: Identify deviations from the normal mechanisms.
Objective 4: List the appropriate maneuvers, adapted for upright positions, to restore the mechanisms back to normal.
Objective 5: Summarize the research evidence for breech birth in an upright position.

Abstract:

For more than four centuries, midwives and physicians have documented maneuvers to assist breech births. This lecture reviews all named obstetric breech maneuvers, which vary by technique and popularity, but all involve a supine mother with an immobile pelvis and a baby emerging against gravity. The lecture documents a new approach to vaginal breech birth: upright birth with mother and baby actively participating in the process. This biodynamic approach combines gravity, maternal movement, and a baby assisting in its own birth to create optimal conditions for a successful vaginal breech birth. I discuss recent studies documenting how upright breech birth leads to shorter labors, fewer birth injuries, fewer maternal injuries, and fewer maneuvers compared to supine breech birth. Because upright breech birth has easily recognizable mechanisms, which I will cover briefly in the lecture, providers can confidently know when the progress is unfolding normally ("Respect the mechanism") and when assistance is needed ("Restore the mechanism"). The lecture, I introduce and demonstrate maneuvers have been developed specifically for upright breech birth when the birth deviates from normal.

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Durations: 165 mins
Session 4: Clinical aspects of physiological vaginal breech birth

Dr. Hayes is an OBGYN with an academic background and a passion for science and its proper application to clinical medicine. He has worked for Médecins Sans Frontières and has attended births in high- and low-resource settings and in both home and hospital. Physiologic breech birth and supporting the training of breech birth attendants are particular interests of his. Before joining Breech Without Borders in 2019, he had a home birth practice in Asheville, NC at Harvest Moon Women's Health. Dr. Hayes pursued training in vaginal breech birth during both medical school and his residency in Obstetrics and Gynecology, at a time when instruction in vaginal breech birth was no longer routinely included in the training of obstetricians in the United States. He has performed an estimated 140 vaginal breech births using traditional obstetric maneuvers in dorsal lithotomy positions. In 2016 he hosted a training session on physiologic vaginal breech birth taught by Dr. Shawn Walker, PhD. Since that time he has been fortunate to attend many more vaginal breech births with a 100% vaginal breech birth rate and no significant complications or instrument interventions.

At the end of the session the participant should be able to:

Objective 1: List and distinguish the accepted and controversial selection criteria for VBB.
Objective 2:Describe a frank (extended knee) breech presentation and distinguish from non-frank (flexed knee) breech presentation.
Objective 3: List the fetal movement events that begin with the onset of rumping and end with the completed birth of the baby, including the approximate time line for those events.
Objective 4: Identify the outward visual appearance of the fetal movements listed in the above objective and connect each with the underlying mechanism.
Objective 5: List the measures of fetal assessment available during breech labor.
Objective 6: List the advantages of upright maternal position in facilitating vaginal breech birth.
Objective 7: Demonstrate the mechanisms of VBB on the obstetric simulator.

Abstract:

This session is the first of two that are intended to present a practical framework for the practitioner to approach attending physiological vaginal breech birth. In this session I focus on understanding the mechanisms of vaginal breech birth, i.e., the movements of the baby through the pelvis from rumping to birth, and on what those movements look like to the attendant.

Part I. Normal breech birth:
Vaginal breech birth, unlike vaginal cephalic birth, has the advantage that all of the cardinal movements of the passage of the trunk, head, and upper extremities of the baby through the pelvis can be determined by directly visualizing the movements of the exposed portion of the baby from rumping through birth. The bulk of this presentation will focus on videos of actual breech births, most of which I attended, and relating what is seen to the movements unfolding as the trunk, shoulders, upper extremities, and head navigate their way through the pelvis. I will describe signs that the baby is assisting in its own birth, which both reinforce the traditional assessments of fetal well-being and reassure the attendant that the mechanism is intact and proceeding normally. There will be extensive focus on the timing of the events once rumping begins. The actual passage through the pelvis is normally completed within 7 minutes. Primiparous moms may take two to three minutes longer, and are more likely to require resuscitation; however, the evidence suggests that there is no difference in outcomes between multiparas and primiparas beyond 1 minute Apgars.

Part II. Selection criteria:
I review the various selection criteria for appropriate candidates for a vaginal breech birth and summarizing the evidence for those criteria. Many commonly accepted criteria have little to any support in the obstetric and midwifery literature, so the emphasis will be on those that have reasonable support in at least a portion of the literature. Part III. Abnormal breech birth:
This lecture will review the mechanisms of normal birth with an emphasis and where and what causes those mechanisms to fail. The points of obstruction will be presented obstructions will be shown in videos of actual births. This portion will conclude with the students reviewing breech birth videos, detecting the abnormality seen, and explaining the obstruction causing it. I present a decision tree for deciding when and how to intervene.

Part IV. Maneuvers (Optional)
I review the main supine and upright maneuvers for resolving obstructed breech births

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Durations: 90 mins
Session 5: Classification, nomenclature, and the risks of different types of breech presentations

Dr. Rixa Freeze has a PhD in American Studies from the University of Iowa. Her doctoral studies focused on the history of healthcare and medicine with specialization in pregnancy, childbirth, and maternity care. Her dissertation examined why women in North America choose unassisted home births. She worked as a visiting assistant professor for 9 years at Wabash college. She has published two articles about home birth: “Staying Home to Give Birth: Why Women in the United States Choose Home Birth” (JMWH 2009) and “Attitudes Towards Home Birth in the USA” (Expert Review of Obstetrics & Gynecology 2010). She recently published the article “Breech birth at home: Outcomes of 60 breech and 109 cephalic planned home and birth center births” with BMC Pregnancy & Childbirth. In 2019 she published an article about outcomes of breech at home, birth centers, and hospitals (Midwifery Today) and a book chapter “Freebirth in the United States” in the 2020 book Canary in the Coal Mine. She is the founder and president of Breech Without Borders, a 501(c)3 nonprofit dedicated to breech training, education, and advocacy.

At the end of the session the participant should be able to:

Objective 1: List the various breech nomenclature systems used around the world (2-tiered system in French-speaking countries, 3-or 4-tiered system in English-speaking countries, 5- to 7-tiered system in German-speaking countries).
Objective 2: List the 7 types of breech presentation and identify hip flexion/extension and knee. flexion/extension for each type.
Objective 3: Describe the main risks and outcomes (umbilical cord prolapse, head entrapment, neonatal morbidity/mortality, rate of successful vaginal birth) for planned vaginal birth of different types of breech presentations.
Objective 4: Identify weaknesses or gaps in the existing literature on type of breech presentation.

Abstract:

This presentation first reviews the different nomenclature systems for breech presentations and shows how they are often overlapping, contradictory, and unclear. Borrowing from Susanne Albrechtsen's work, we propose a universal nomenclature system that recognizes at least 7 types of breech presentations based on hip and knee flexion or extension. If we can adopt a clear, internationally recognized terminology, then we can better understand the risks of the various types of breech presentations.
Topics such as outcomes of vaginal footling breech, the distinction between a true “standing” footling and a “dropped foot” breech, risks of umbilical cord prolapse depending on the type of breech presentation, differences in birth mechanics between frank and nonfrank presentations, and differences in in-labor cesarean rates depending on the type of breech presentation.

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Durations: 225 mins
Session 6: Breech simulations: Recognizing and correcting abnormal breech labor

Dr. Hayes is an OBGYN with an academic background and a passion for science and its proper application to clinical medicine. He has worked for Médecins Sans Frontières and has attended births in high- and low-resource settings and in both home and hospital. Physiologic breech birth and supporting the training of breech birth attendants are particular interests of his. Before joining Breech Without Borders in 2019, he had a home birth practice in Asheville, NC at Harvest Moon Women's Health. Dr. Hayes pursued training in vaginal breech birth during both medical school and his residency in Obstetrics and Gynecology, at a time when instruction in vaginal breech birth was no longer routinely included in the training of obstetricians in the United States. He has performed an estimated 140 vaginal breech births using traditional obstetric maneuvers in dorsal lithotomy positions. In 2016 he hosted a training session on physiologic vaginal breech birth taught by Dr. Shawn Walker, PhD. Since that time he has been fortunate to attend many more vaginal breech births with a 100% vaginal breech birth rate and no significant complications or instrument interventions.

At the end of the session, the participant should be able to:

Objective 1: Describe the intervention decision tree (recognize abnormality, determine whether intervention is necessary, & select the proper intervention).
Objective 2: Identify the external manifestations of abnormal vaginal birth and connect them with the mechanism of failure.
Objective 3: Describe the midpelvis rotational maneuvers and what situations they are used to correct.
Objective 4: Describe the inlet and midpelvis flexion maneuvers and what situations they are used to correct.
Objective 5: Describe the pelvic outlet flexion maneuvers.
Objective 6: List the indications for intervention.
Objective 7: Distinguish between maneuvers to restore the mechanism and maneuvers to extract the baby.
Objective 8: Explain the phrase “hands off the breech” and what the dangers of intervention are.

Abstract:

This is the second of two sessions and follows the presentation of normal physiologic breech birth. The focus will be on recognizing abnormal breech labors and birth, understanding the mechanism that has failed, and mastery of the maneuvers required to restore the mechanism and assist the birth.
This session puts all the pieces together using obstetric simulations. Dr. Freeze’s simulation videos demonstrate all of the upright and supine manvuers, one by one, using both a doll & pelvis and an obstetrical simulator. Students will follow along with a doll & pelvis as they watch the videos.
Dr. Hayes’ simulations present clinical scenarios. The instructor will create an obstruction on the simulator. Each student will identify the type of obstruction and select an appropriate maneuver to resolve it and then perform the maneuver. By the conclusion every student will have identified one of each general category of obstruction and performed at least one of each type of maneuver correctly.

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Accreditation


Midwifery CEUs - MEAC Contact Hours
This continuing education program has been approved by the Midwifery Education Accreditation Council (MEAC) for 13 Hours of Education / 1.3 CEU's - Equivalent to 13 NARM CEU's.

ACM CPD Recognised Hours:
This program is approved for ACM CPD Recognised Points equivalent to 13 hours of education by the Australian College of Midwives (ACM).

ACNM CEUs:
This program has been approved for 13 hours of education by the American College of Nurse Midwives. This credit is applicable to Nurse-Midwives, Certified Midwives, Registered Nurses. May be accepted by other certifying bodies.



If you have already participated in this program, you are not eligible to receive additional credits for viewing it again. Please sent us an email to [email protected] if you have any questions.

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