How much training do midwives get? Shoulder dystocia video...

[peanutdream]

I was just watching this video and thinking how fascinating is was. I thought it was brilliant the way the midwives get to practice on a model like that, and it suddenly struck me that they have done a good deal of training - I just don't know how much and what exactly.

I had DS by EMCS due to brow presentation and overall have a pretty positive feeling about the birth and labour. The midwives in this video are learning about the pelvis and ways to release babies that are presenting badly. Because of DSs brow presentation, I am very interested in the positioning of the baby and how it can be changed/encouraged etc... hence looking at Spinning Babies - thanks to a link on here.

I suppose I'd like to have more faith in midwives as last time, I didn't have much experience of them tbh - they certainly didn't have anything to suggest regarding the positioning of DS although the one that was there constantly was giving me amazing lower back massages so no actual compaints! I suppose as I was at home mostly, by the time I got to hospital it was a matter of hours before the CS as it progressed reasonably quickly and DS was getting increasingly stuck/distressed - at 6cm we had to make a decision. The constultant was present quite a bit - discreetly in the corner a lot of the time - looking more and more concerned about the heartbeat. Is this because they literally cannot do anything about brow presentation or because midwives are not really taught about positioning and ways to release/help badly presenting babies? I can't really believe that tbh - it is surely more likely simply my ignorance about their training and experience. I'd like to have more faith in them though for the next one - due November.

Any thoughts?

TIA

My 2nd was born by EMCS for brow presentation and distress. I was fully dilated by the time the decision was made and have been for 3 and half hours.
Whilst the whole experience wasn't the most pleasant, I can't fault the care I was given before, during and after my section from the midwives.

I have no idea about brow presentation, and have chosen personally not to google as I may feel guilty if it was avoidable on my part.

I am due number 3 in september and hopsing for a VBAC, so keeping everything crossed (except legs) all goes smoothly.

I'm no expert on this so don't take what I say to be gospel. Shoulder dystocia is very different from brow presentation. Brow presentation stops the baby from getting past the pelvis because their head is in the wrong position. To fit down the birth canal the baby's chin has to be on their chest, so their head needs to be bent forward. If their head is bent back then they can get stuck. Often the midwife can't really tell if the baby is in this position until it's too late due to the amniotic sac being in the way or just because they can't get a good feel for what part of the baby's head is presenting. Often by the time they realise the problem the baby has become well and truly stuck and there is very little the MWs can do.

Shoulder dystocia occurs when the head has already been delivered but the baby hasn't spun around and their shoulders get stuck in the pelvis. This is much easier to rectify (although still very difficult) as the baby is already partially out and so the MW can manipulate the baby to get them in the right position to free them.

Basically MWs are very very skilled but they're not surgeons and internal procedures are really outside the scope of their jobs. That's why for the most part doctors are called in to administer forceps etc (although some MWs are now being trained in this). There are some problems that they can deal with and others that they can't and a big part of their skill is knowing when to call for help.

thanks for both posts :)

i know that brow and shoulder are totally different - it was more that on the video the midwives had a very cool fake pelvis to learn with to learn about positioning.

i have been reading recently about positioning of the head and how it can be moved while inside still above the cervix, either by the midwife or the mother moving in a particular way to shift her pelvis.

tbh the OP wasn't very clear - i was rambling a bit. midwives must be well trained - i was just wondering if they knew about this positioning malarkey or if it was quite new....

thanks though...

My MWs seemed very aware of positioning and tactics to encourage good position at the end of pregnancy and for the early stages of labour. It was also covered in ante-natal classes with a model of a pelvis and a doll! This wasn't NHS though.

I guess that if baby is an undetected brow presentation or shifts during labour by the time it's picked up it's too late.

brow presentation isn't unbirthable, though, only transverse is

there is achicken and egg situation going re: training for midwives and obs on problematic vaginal births eg breech- the less that are done, the less opportunity to train on them there is, therefore skill levels decrease, making these births more dangerous and then justify not doing them at all so then there are no skilled practitioners left!

hi darlene, i have read that brow presentation can be birthable but DS was well and truly stuck and getting distressed - he was very bruised in a ring around his head and i can't see that unless he had been able to move his head he would have come out. i was happy with the outcome tbh - but i do wonder if i could have helped him move his head earlier on in the labour when the contractions hadn't squished him in so much. like someone said though the bag of waters was there for quite a while - it was only when they broke that we discovered the presentation...

i have read the brow presentation can work with a smaller baby/bigger pelvis or if it converts to face although some texts appear to say that it is undeliverable in most cases - ina may has delivered one but another of hers was a cs...

like you say it seems mad that the more difficult births are not done as much so mws don't get the experience and it goes on and on reducing the skill level... i have seen ina may's 'running start' on spinning babies to convert one of the malpresentations, and was wondering if midwives have this kind of expertise...

sorry wrong sign in - frodo is peanutdream!

I never had any training in my midwifery training in positions to rectify a brow presentation. Didn't even have any in how to rectify an OP position though learnt this myself since on paid for extra study days of my own choice.

ok thanks vivalebeaver

I found this discussion really interesting as I'd been wondering a similar thing about midwife training. DS was LOT and asynclitic and had to be delivered with Kiellands forceps after failed manual rotation. He was ROT in the final weeks of pregnancy (was told by my midwife to sit on the ball and not lie on my back, plus did lots of swimming and yoga) and was presenting LOT when I arrived at hospital. When I was examined at 10cms dilated the midwife said he was now OA, his position was only correctly identified by the registrar when I was transferred to the labour ward from the midwife-led unit after 2 hours of pushing and going nowhere. I was told at my debrief that he was unbirthable from the position he was in but having a look at the Spinning Babies website it suggests that there are actions you can take without resorting to intervention. I can't remember really being given any advice about sorting out the position during labour, except for keeping upright (was most comfortable in this position anyway). Even if the midwife doing my VEs had noticed his poor position, the hospital policy is 2 hours max of pushing before intervention anyway. It makes me wonder why malpositioning, which seems to lead to so many cases of assisted delivery and EMCS, doesn't seem to be given much emphasis by midwives. Why aren't they recommending OFP to everyone?

McRoberts is for shoulder dystocia which midwives do get an awful lot of training in. What they don't get much/any training in IME is trying to change or prevent a sub-optimal fetal position.

I think this is because the majority of midwives/Drs believe that different maternal positions won't have any effct on fetal position. I've certainly heard Drs say this. Obviously everyone knows that being upright, etc is good but that seems to be as far as it goes.

As a student I had a very expereinced mentor who would say to women well your baby is facing in this direction so I now need you to adopt X position. I learnt a lot from her whle other mentors neevr mentioned it either to me or the women. I never had any classroom teaching on the subject.

I did really ought to look at some research to find how evidence based maternal positioning is. At the minute I do it as I saw my expereinced mentor do it. It seemed to work quite a lot of the time but certainly not every time.

Does anyone have any suggestions for reading up on manouevers to change a suboptimal position, for a non medical audience, ie pregnant women? Only DS was LOT and hauled out of the emergency exit and I knew something was wrong and he was stuck but was ignored. When the mw finally realised I wasn't just being crap at pushing but he really was unbirthable she didn't offer any positional suggestions and looked really pissed off at my poor efforts. I'd like to have some backup techniques for myself incase my VBAC mws are equally disinterested. Would Ina May be a good starting point?

Poppet - this is a topic close to my heart. DD1 was OP and, as Viva said, the midwives were basically completely disinterested in anything other than being 'up and mobile'. It ended up with failure to progress, ARM, then syntocinon and an epidural, until finally forceps.

DD2 was born last week with my amazing doula. I knew something moved into the wrong position part way through my early labour. The pain suddenly changed. When my doula arrived, she did loads of positioning work with me during contractions, including some excrutiating 'inversions', but suddenly something was right, and DD2 was then born so fast she didn't wait for the midwife (it was a planned homebirth by the way, just didn't plan it quite that way!).

I am totally on a high and really believe that it was the positioning stuff at an early enough stage that made the difference. However, I don't know how a pregnant woman would amass the knowledge (or have the presence of mind in labour) to necessarily take control herself. Would a doula be a financial option for you? A trainee can be pretty cheap.

poppet the only things i have come across are spinning babies and ina may's running start - but that was on spinning babies and it is to correct a particular suboptimal position. ina may's guide to childbirth might have something in it as she is well into natural birthing - am reading spiritual midwifery at the mo and its great but lots of birth stories rather than a handbook iyswim

so where do doula's learn this type of stuff Secondtimelucky? Is spinning babies the only thing? and i agree that it is difficult in labour to have the mind to do it yourself - you need someone to help. that is why i wanted to know if midwives have this type of expertise, but it seems they don't - in general

Give me a minute, there was a doula that gave me advice and a couple of things to help position. Just have to remember title and find thread.

www.mumsnet.com/Talk/pregnancy/1195738-Husband-doesnt-want-me-to-have-a-doula/AllOnOnePage

It is selinadoula near the bottom of the thread, she has also added a couple of links.

that's brilliant nunnie, thanks

Thanks so much Nunnie, hope things go great for you at your birth. I've been umming and ahhing about a chiropractor because I suspect I have a duff pelvis. The doula idea is interesting, not least because we don't have a clue what we're going to do re childcare as we have no family close so DH is unlikely to be able to be there for all the labour. I guess I'd not thought we were the sort of people to get a doula, what a silly preconception. I also fear DH might take it as a criticism of how he helped me last labour. Plus it was so traumatic for him I want him to be here, in case it goes well, and he can get some closure too.

Poppet - I would really recommend a chiropractor. I have a bit of a duff pelvis too, and I do think it helped.

I'm not sure where doulas learn this stuff. Presumably because they are interested in natural birth and make it their business to educate themselves - much like some interested midwives (particularly those in birth centres, community or independent) do. My lovely doula is on MN, so you never know, she may be able to answer herself. I'll never know for medically certain that it was what made the difference, but in my own mind I am sure it did.

Childcare was one of the reasons we had a doula - so that DH could ferry DD between friends if necessary. Actually, DD2 arrived overnight, so no problem. Hiring our doula was no criticism at all of the help DH gave me last time. He did everything he could in a very difficult situation. Having our doula there did not replace him in any way, though if anything it enabled him to do a more effective job of supporting me this time round. He was physically and emotionally absolutely necessary. The doula, if anything, fills a gap between where your partner leaves off and where the midwives step in, not a deficiency with your partner (unless you actually need them to!). It really is the best money we have ever spent.

Mmm this has got me thinking, I know a lovely lady who founded a wonderful charity for pregnant women and new mums who does some doulaing - is that even a word? - as well as birth debriefs and I know and trust her because she taught me pregnancy yoga when I was epecting DS. She doesn't charge masses it's actually for a donaation for the centre, but she only agrees in certain situations, problem is she's in Edinburgh and we're now in Fife. Speaking of which I'm having a mare of a job finding a local chiropractor who does Webster technique. Lots to think about. Thanks ladies.

Hi ladies.... i was reading your thread out of interest and saw you were discussing Doulas. I have been a Doula since 1994 and just wanted to let you know that if you ever have any questions please feel free to contact me [email protected] or through my site which is www.northlondondoulas.co.uk have a nice day. Victoria.x