 So before we actually introduce, do you want me to introduce you first or get them to do the mentee thing first, Molly? We'll do the mentee, we'll do the mentee survey first. The word cloud, please. Right, we're going to do word clouds. This is a bit of interaction going on. Some of you might have met this before. If you could go to mentee.com or your smartphones or on your computers and put that number in. We have a question for you. What is the question that says it on the mentee thing, but I haven't seen it. I can't see it at all. How do you feel? What are your feelings about labor dystocia? Difficult parts. Yeah. When you're when you're listening to the women, hearing their stories or looking after them. Yeah, what do you feel? Okay. Okay, we'll let that happen. So meantime, I'm absolutely delighted to introduce Molly O'Brien as one of our keynote speakers here today. She has over 25 years in midwifery, 20 of which were working in clinical practice as full time midwives in the NHS. So she's a very experienced midwife. She's a birth preparation teacher, an associate university lecturer, and she creates some teacher's courses on biomechanics for birth for midwives and other birth related professionals and associates. And back in the year 2000, she campaigned for midwife led birth units. So, Molly, I will just hand the baton over to you and I will shut myself out. And delighted to hear what you have to say. Thank you. Thank you, Linda. I'm going to go straight to share my screen with everyone so we can have a look at that mentee meter word cloud that you've just participated in. And if you haven't participated, please feel free to do so now. The is mentee.com and the code is on the top of the screen here. And as you can see, we have a lot of negativity around this subject. We feel powerless, we feel disappointed, challenged, frustrated and we're aware of the suffering that's attached to this situation and we're feeling responsible and defeated and insecure. There are many negative emotions and I'm just going to stop sharing and back to the screen again. That is a problem for us. It's telling us that we don't know enough about this subject, the subject of difficult birth. And that's what I'm going to be talking about because I've called it biomechanics because actually how the baby passes through the pelvis is one of the reasons that we find it's difficult and of course, fear is involved as well. So it isn't cut and dried. It's actually quite complex, but certainly our knowledge of how that baby travels through the the pelvis is incredibly inadequate for the needs that we have to support women through their birth process. Now, here we are celebrating the International Day of the Midwife and these are, this is our competencies that reflect our philosophy and we have a specific philosophy and that is to support, protect and optimise physiology and pregnancy and labour. We need to promote and support health behaviours that improve wellbeing. We want the women to be as well and healthy as they can be as they enter their journey into motherhood. We need to trust the women in the process. This is our remit as midwives. Our care combines art and science such an appropriate title this year for International Day of the Midwife. Our midwifery care is holistic. We look at the whole person and I know that I'm looking at the mechanical element, but we can never separate that from the whole person and everything's interrelated. But the fact is we don't look at the mechanical element at all. And that's why we need to actually have a good look at that specifically. And our scope of practice is dynamic as we learn more, we change our and grow through our career as we learn more about birth. This is a very exciting job and fascinating job that we have. This is, that picture comes from Becky Reed's book, Birth and Focus. And I think it really illustrates being with women right there by her side. So Labour dystocia I mentioned before and you indeed participated in that word cloud. But it's hard to address if we can't define the issue. We don't even, we do not have a consensus on the term Labour dystocia. We really don't know what it means. The definitions in the textbooks are actually very unhelpful. They describe some of the symptoms that may occur and they also use derogatory terms towards women and their birth process. It is indeed, in a sense, obstructed labour because the baby is struggling to find a way through the pelvis with ease, making it much more difficult. In fact, Labour dystocia means difficult labour if it's translated directly from the Greek. That's what it means, difficult labour. But we say in our textbooks and in our midwifery training and in medical training that is a failure to progress. So we have inefficient contractions and there is insufficient maternal effort. She's just not trying hard enough. It's abnormal, it's dysfunctional. These are really derogatory terms that we're using that are very unhelpful and actually don't get to the root of the problem. Now the root of the problem indeed may be associated indeed with a suboptimal position of the baby and that's recognised in some of the definitions. Due to soft tissue or bony disorders of the pelvis. And that's getting to be closer to what we need to know is why does the baby get into a suboptimal position? What is going on with the soft tissues, the muscles, the ligaments, this complex articulated piece of architecture within our body which the baby passes through? So we need to ask the right questions and we need to understand the answers as well. So if we have to be detectives, this is our work, what skilled work we have. And very often we're doing this without a relationship-based model of care and that makes it more difficult. These midwives, many midwives are walking into a birth room never having met this woman before in their lives and she, them. And so that makes it harder for us to understand has birth gone awry? Is this within the normal parameters of birth physiology unfolding in its various patterns? There lies a problem because midwives are not seeing physiology unfolding in many of our maternity, our current dominant maternity model of care which is a bimedical model. So we need to start thinking in a different way. Why does the baby find that journey so difficult? This is what led me to explore it. Is our understanding of anatomy and physiology enough? Do we know how that works? Is she suffering from a neurohormonal imbalance? Is there fear? Does she have the right environment and the right support because those are really essential elements of the birth process ability to unfold? Is there a mechanical issue? How would that feel? And what would happen if we switched around? Because the biomedical, the technocratic model of care is focuses on quantitative measurements, time, hours, whereas midwifery actually is founded in qualitative measurements where we are interested in the quality of experience rather than the quantity of time. And what would happen if we actually were really interested in what she knew about her own body and that baby traversing her pelvis on its way to the outside world? Because the woman has inside information and we need to tap into that and understand and value what it is she's telling us. And we certainly can do that through watchful attendance, which I will mention later on. But first of all, the in-depth understanding of anatomy and physiology is crucial so that we understand better how that may express itself in movement, in pain, in unfolding of the physiological process. But here we have a problem because it is an understudied region of the body, certainly from a biomechanical perspective. And this is Delancey, who is an eminent urogynecologist, still saying this in 2022. He says, we're confused about pelvic floor anatomy, the illustrations. We're really not quite certain about that. And we do understand that we haven't focused on this. We don't understand why birth becomes difficult. And that's why we have sometimes quite brutal and ineffective interventions that do not improve outcomes. We make assumptions about the pelvic shape. And this is in midwifery training and in medical training that we are still focusing and using the Caldwell-Malloy classification from the 1930s. That says there are four pelvic shapes and the best one is the gynecoid pelvis. Now, this is the model of the gynecoid pelvis. It is the only model that you can buy. And yet it is untrue that this is the normal shaped pelvis. In fact, there may be, it's most likely that there's a spectrum, a variety of shapes of a mixture of shapes. And Leah Betty has done work on this and others too. That debunks the whole idea of the gynecoid pelvis being the best, being the normal. Because what comes with that is also our view of how that baby passes through the pelvis. Now, this pathologizes the pelvis. It pathologizes many, many women who don't have a gynecoid type pelvis. And yet their experiences of giving births are equally valid. But we regard them as being abnormal because this baby is coming back to back. But that might be perfectly normal for that woman's pelvis. We don't understand the full body, what's going on, what's passing through the pelvis, how it's affecting the balance of the pelvis, the space within the pelvis, and optimal positioning and alignment of the pelvic organs, which is also the uterus, of course. No, we are asymmetrical, we have some mobility and flexibility, but there will be optimal functioning. And it will be affected by how our bodies are balanced. And the effect that connective tissue has, the effect that the ligaments and the muscles and how the body is aligned will have a potential influence on how that baby is passing through the pelvis, what space it has to do that. There's our ligaments that hold the uterus in place. And these are attached to the pelvis themselves, to the pelvic floor and to the bones. They keep everything in order. And the sacrum. The sacrum moves. It is held in place with the sacrociberus and sacrospinus ligaments. So there has to be some flexibility there so that these can move optimally and release space for the baby as the baby is travelling through. So our job is to understand that better. So we can reduce the potential for difficult births. By supporting birth physiology, that's our remit. That's the International Confederation of Midwifery, the NMC Code of Proficiency. This is what we do, supporting birth physiology. And so we would advise women to take up good, healthy habits and postures to support their physiology. We need to recognise the signs of difficult labour and that's a problem. It's a problem for us because in our highly medicalised maternity care systems, birth has become so pathologised and so many interventions that it's difficult to know what is normal. Is she suffering? Is she in agony? Have we normalised that? Would we recognise it? Do we listen to her? And we can do much better if we have the chance to do our work of watchful attendance. And we can resolve the problem once we recognise it by working with a woman and listening to her. And we can resolve that by optimising birth physiology and that's the way we can unlock that birth. That she unlocks her own body by making more space for her baby using physiological postures and techniques. But the ultimate solution is one that she finds herself, of course. We need to be able to give her that opportunity to do so. So freedom of movement. But to move instinctively, you also have to have trust and confidence in your own body. So this goes right back to education as well, birth preparation. So we have meaningful birth preparation classes of physiology informed to help women understand how their bodies work. So they can trust the process. But we also need to trust the process and the woman. So understaffed physiological birth is quite rare. It usually happens in the midwifery model of care, which is at home or in birth centres. Midwifery led birth centres. But those who give birth, for example, alone at home, unassisted, they're choosing free births, we find that they're listening to their own bodies. Those who choose that, they maybe have more confidence in the process. And this is a description coming from a study by Mackenzie Montgomery in 2021, where they looked at those insights they gained from those women who were free birthing in the United Kingdom at that time. And they felt instinctively that the baby might be stuck and they would move and make more space for their baby. And it's as simple as that, really. Wow, wouldn't it be wonderful if everyone had that? If everyone had that understanding and that connection with their own body where they could move instinctively. Now, some of them that will be helpful and that will work and others may need more assistance. And that's where we come in as midwives. So first of all, reducing that potential and mention the birth preparation classes. We can redesign them and it is actually central that we do that. We need to make sure that women understand how their body works. And first of all, we need to understand that too. And we need to share that information so that we all have a better understanding of the variety of patterns of physiology that actually goes with the variety of pelvic shapes that we have. And pregnancy advice would be walking, swimming, dancing, yoga, stretching, movement, basically. And this is problematic for us in our modern lifestyle, certainly in the developed world, where we're very sedentary and we're not moving. And nutritionally, we're rather deprived as well across the globe. We're either not got enough food or we're eating ultra-processed food. So our ability for our physiology to unfold is depleted in that way where we've got very unhealthy lifestyles. And this is something that midwife can address. And the movement can be very simple, but we need to make it achievable. And that birth environment, we need to cherish those practices that support and optimize birth physiology. Can we rearrange the birth room? Can we create a default environment that supports birth physiology, no matter what kind of birth she's expecting to have? Even if she's got complexities, we can at least give her the opportunity to get up and move around to use a birthing ball if she wishes to use flexible, sacrum positions which we know actually give the baby more space to come. And those are the forward-leaning ones, the nailing forward, lying on your side, lifting your leg up, doing whatever feels right for you and the most instinctive birth positions are the best ones. But when someone is lost and doesn't know what to do with herself, then we can advise because we will understand that those positions make more space for the baby. And CTGs, we've got technology in the room, but this technology is not based on evidence. That's another story, isn't it? But if we're not going to change it overnight, but if we can at least mitigate the risks attached to that technology, then we will be moving forward a little bit. So telemetry so that the woman can get out of bed, who she can get in the pool if she wishes and have some movement. She should not be restricted and we do need to have a conversation about the use of that technology that is not supported by evidence. But the freedom to move, I just cannot say enough, that in itself is simple yet complex because women are not seeing that. So culturally we don't think it's important because we just see birth taking place on the bed. So we have a lot of unraveling to do. And we can help by making sure that the bathroom is set out that gives an impression that you can move if you wish. And we can encourage that. Upright positions do create shorter labours. We know there's less intervention, there's less severe pain. And actually women are much more satisfied with their experience compared to those that are in a semi-recumbent or supine position. So this really does matter. It changes the shape of the pelvis. It helps the baby find the space it needs. And dancing can be so joyful in the bathroom. With stepping back and hiding away so that she doesn't feel watched. Again, another skill of the midwife to observe but not to be observed herself. I do love Labour hopscotch that's come from Ireland. And it's a little bit of light hearted fun that suggests mobility. It's a suggestion. It's not prescriptive. It's a suggestion. Would you like to take a little bit of a moment in the shower? Would you like to go for a walk? Do you want to go to the toilet? Do you want to get in the pool? Do you want to go on the birthing ball? Here are some ideas as a reminder for movement that we're not prescribing that, but we're encouraging the possibilities of movement because birth is dynamic. But here is, for me, one of the most important elements of our work is the art and practice of watchful attendance. And that is actually using intuition as well. One might say, well, what's intuition? But it's actually recognizing and understanding patterns. But if we don't see that pattern unfolding, there's variety of undisturbed physiology unfolding. Then how can we know when it goes awry? And that is one of our jobs is to tell the difference. And we do that alongside the women because we're listening to her. We're listening to her unobtrusively. But if she tells us this doesn't feel right, we have to take that very seriously because she's giving us inside information. How is she moving? Where is she experiencing the pain? You might see her actually clutching an area. She might be rubbing her thighs or her back or the front of her pubis and bent forward. And on her face is there agony? Is there excruciating pain when she does that? And is she very early on? Does it correlate with the progress in labor? And all these things will give us an understanding of whether or not she's having a struggle. Is she distressed? Is she suffering? Now we do know that labor is very intense, of course. It is intense and powerful. But with the right support and the right environment, it doesn't have to be distressing. And that's the support partner and the midwife. And the do-aliz job is to bring her back. When she teases us on the edge and she feels fearful and she thinks she can't do it. And you remind her. And she takes a big breath and she's fine again. She can do that. But when you have an obstructed labor, it doesn't feel like that. It's very different. And we need to recognize those signs when somebody is suffering. Not to poo-poo it and say, well, she's not, she's not, she's two centimeters. She's only two centimeters. She's only three centimeters. We can't, she's not an established labor. And yet she may actually be suffering from a primary labor dystocia, which we don't recognize. And she's suffering. And that's not good enough. So we need to hone our skills and our understanding of how the baby comes through that pelvis and what that means for the quality of experience. How long are the contractions? That would be a great question to ask. And it's one of the questions I would ask on the phone. And I'm speaking to women and I say, how long are contractions? She might say, oh, two or three minutes. They're lasting two or three minutes. That's unusual, isn't it? It's not what we expect. But if we think why, why would she be feeling that? And it might be that she's having double peaking contractions. She might be having coupling. And we know those correlate very strongly with a mechanical issue or a suboptimal position baby. We see it on that piece of technology, the CTG on the piece of paper. But this is actually asking her, how does that feel for you? That's going to feel like it's lasting two to three minutes. Or it could be lingering pain, lingering building up and lingering afterwards. So having a better understanding of the variety of patterns, of how some women actually carry their babies very high up, where the babies don't engage until they get into labor. And the first part of labor is the baby entering the brim and passing through the brim of the pelvis. The baby meets the pelvic floor. They go straight into second stage and push their baby out. Now for some women, that'd be absolutely normal. And those women maybe tend to be more from Africa, where they have a more anthropoid-type pelvis shape. Those babies, they're more likely to carry them in an OP position. Equally, they could be in an OEA, just the pens, but they can easily carry their baby back to back. And yet, if we focus, hyper-focus on that as being a problem, we're pathologising them. And their baby's not entering the pelvis. What's going on there? Is that a problem or not? Not a problem. It's the way she's doing it. So we need to understand this variety of physiology unfolding and stop pathologising. Recognise when it does become difficult, but let those women who are breasting in a different way. Not the one that we're told is the right way, which is the gynecoid pelvis and its mechanisms. Let's forget about that. Is she okay? Is she struggling? How's it going for her? These are the kind of questions that we really want to be asking. I'm just actually going back. I want to say one more thing about that. I want to ask everybody to consider the possibility of spending this time watchfully attending in the birth room, in the biomedical model, where most midwives are working and where most women are giving birth. That's where the majority give birth and that's where we work. Now, how difficult would it be for you to sit in that room quietly and watch and wait? I would say that that was quite a challenge. There may be pockets of great practice in some of the obstetric units, but in general it is there's an emphasis on speed. Let's get on with this and we have no time to sit quietly and watch and wait. And therefore we lose a lot of valuable information collecting from the women themselves, how they're moving and so forth. So what we can do when we do recognize that there is an issue and she's recognized there's an issue, then we can optimize physiology or she can optimize her own physiology and make more space for her baby. And that works the majority of the time. And sometimes we need to help and I'm grateful for the obstetricians and their skills because they save lives. Thank you very much for being there. But let's optimize physiology first because many, many women will be helped and that power balance is shifted as well because this is the women doing it themselves. We will guide them, we will suggest to them perhaps you might like to rotate your thigh inwards as you can see in the middle picture to the bottom where the midwife here is demonstrating the internal rotation of the femur using a peanut ball and she's just opening the pelvic outlet. This is also called Kiko which is knees in, calves out. But mechanically what it's doing is internally rotating the femur and you can feel that for yourself if you wish. You want to feel your ischial tuberosities. So that's your bum bones and there they are. So that's ischial tuberosities and this is the transverse diameter of the pelvic outlet. Now something that midwives do which actually hinders birth is that we say open your legs and make more space for your baby but it doesn't do that. We need to stop doing that immediately. First of all we should not be just jumping and instructing all the women to do the same thing every single time. There's no need to do that. We should just leave well alone if it's all going well but if we see that she's struggling we should advise her with something that will help not open your legs wide. So what we want to be doing is when we do need to offer some assistance is make sure that these bones here can widen a little. So I want you just to put your hands underneath the bottom and feel your bum bones. That's your ischial tuberosities. Just feel them now. I want you to just do you can actually try out the first one that midwives often say all over the world and they need to stop it so we can start with that. You can feel what that does. Feel your bum bones. Have your knees in front of you and now open them wide as midwives instructing and you can actually feel that that pushes them inwards a little and actually reduces the space. So we've just made it harder for her. Well baby will still come out but we've made it more difficult. So let's do the other one that actually does make more space and if we need to offer that information then we will be helping her. And so feel those bones again underneath in your bottom your ischial tuberosities and now internally rotate your knees your femurs inwards and you can point your toes towards each other and the heels and your calves are away to the outside. You will feel that those bones now open up and that has increased the pelvic outlet and that's valuable information and that means that we understand anatomy and physiology so we need to have correct training. We need our education to be updated bringing useful information in. Not this nonsense about obstetric conjugates based on a measurement of a static structure that is not even of the shape probably of most palvices. It means nothing. We need to stop that in our training re-educate ourselves, educate the women and actually start to do our work supporting and optimizing physiology and using the art and skill of watchful attendance. Thank you. I had just turned on my mic to say probably time soon and I thought that was beautifully timed. Thank you Molly. You're welcome. I don't know if you've been distracted by the chat but there's been quite a few comments. No I haven't actually. No questions, just lots of people agreeing with every word you say basically. Good. But does anybody have a question they wish to ask because they are very welcome to do that as well while Molly has a great look at all these wonderful comments. Yes and Celine's mentioned fear. I mean we need more investigation. I'm fear and mechanical element are closely connected as well and that's something we need to investigate a little bit more. Can I just say something about that because there's an associate professor of physiotherapy called Sinead Dufour in Canada and she's suggesting that pelvic girdle pain is not necessarily a mechanical issue. In fact the physiotherapist who care for those women with pelvic girdle pain really can do very little for them. We give them a bell and some crutches but she's suggesting actually it's coming probably from fear and I think she's got a very good point and that's something we need to investigate more and I do wonder if some of the mechanical issues that we find in labour obviously sedentary lifestyle, bad posture habits that we have will contribute to that but I think fear is going to be really associated very strongly with that as well. That's very very interesting. Jane Houston has asked a question which I know is a huge loaded question. Can you speak to suspected fetal macrosomia? If I hear one more woman being told that her baby is so big she needs induced at 37 weeks to grow. I think it's very rare that women are going to grow babies too big to pass through their pelvis. I think we have possibly got an issue with some because nutritionally we're eating ultra processed foods and that may well mean that we are sometimes growing babies that are a little bit bigger than we used to grow. I'm not sure if that's going to make a huge difference. I think what does make a huge difference is the number of women giving birth on the bed and in fact in the UK 27% are in a Lysotomy position now this is biomechanically disadvantageous. So we're actually making it more difficult and then when the baby doesn't come out we say oh look at your baby it's too big to come through but actually we're finding that's not true. I find that midwives are saying to women sometimes they've had a really difficult birth and it may end up in a caesarean they may say to them oh that baby would never come out there and they want them to feel better they want them to feel better that there was a justification for them going through all of that trauma but indeed those women may well go on to have a vagina birth after caesarean of a bigger baby so this doesn't wash really we're going to have to look at that very strongly and I don't believe that this is an issue with little macrosomia. I think women left to their own devices to move and to make space for their baby will be much more helpful than pinning them down on a bed on their back minimising the space in the pelvis and then telling them to do things actually make less space so not helpful at all. No, I totally agree lots more comments of course Yeah Yeah absolutely the wee passenger and the beautiful passage absolutely working together and Margaret saying not just a passenger I know Margaret's going to speaking later and of course the baby and the mother they're dancing together with this, this is movement the dynamic process with the baby moving with the mother and of course the skulls, the plates overlap and the pelvis opens we have a lot going for us because we can actually do this but we are compromised by a medical model a technocratic model of care that actually impedes on the physiology and itself makes breath difficult. Betsy has asked what do you think about asyncratic fetuses, my grandson was asyncratic, you tell afterwards by the shape of his head well again yes and absolutely we do understand it some babies will be what we consider suboptimal for that shape of pelvis now my first baby was back to back and he was also asyncratic and deflexed and that was not suitable for my pelvis and was a very difficult birth I did push him out myself but it was incredibly difficult and it didn't work well at all for my shape of pelvis now a nukohand, asyncratic, deflexed this is all greater diameters that are coming through the pelvis if you've got movement, if you can get up and make space for yourself for your baby then that will be minimized or made a little bit more easily it could be that that will be all you need is that space now I think it's difficult because who's finding this information out and how are they finding this information out they're doing it in labour they're trying to determine midwives and doctors determining how is the baby sitting in the pelvis well that is problematic in itself using a digital examination which is subjective and really quite unreliable and inaccurate it gives us some, it has a value it does give us some information but it might be that that baby was asyncratic at the point where you just happened to do that examination but it wasn't an issue it just happened to be that how the baby was navigating that point of the pelvis when you happened to put your fingers in there and actually it was going to sort its head out later as it came down through the pelvis so again we mustn't jump in and say oh asyncratic, back to back this is a problem unless it's posing a problem but I mean we do recognise that sometimes that does happen of course and that is because of restriction of space so the babies had to get in and again speaking to the women I love that when birth is really difficult and then more space is created perhaps with her own instinctive movement or you may introduce a movement like a sideline release where more space is made and then she says oh oh I just felt something oh I felt a real clunk there and the baby has come out of where it was trapped where it was stuck and she knows that because she felt it and I think it's all about space yeah somebody's talking about the practice of pilvimetry there I think that's terrible pilvimetry is just so so we do not need pilvimetry and it's absurd I mean it shouldn't be and it's not talking about your teamwork anyway and you can't how are you going to measure a pelvis it's so difficult it's a mobile structure articulated and opens up it's been shown actually to be a very ineffective way to measure a pelvis and does the pelvis really even need to be measured again that's that quantitative measurement that comes from the biomedical model and midwives would be looking how are you doing it's like the long latent phase we all talk about well we do understand that that can be an issue for some women getting into labour if they have a mechanical issue it can create a long latent stage but what does that actually mean what constitutes a long latent phase and again the biomedical model the technocratic model the measurement of hours oh well it would be 12, 18, 24 hours or whatever but that doesn't mean anything to this individual woman where she's actually suffering after 14, 18 hours but her neighbour who went into labour at the same time as her is having a similar slow build up but it's different similar in time but different in quality of experience she's fine and she's been making a cake and she's walked and she's bathed and she's napped and had a little something to eat and went off for another walk and went on her breathing ball but the other woman is struggling and is on her knees and that's the difference and that's what we're talking about and I'd rather go with that than say how many hours is it I'm afraid I know you can so people who follow up on where you are going to speak and go and see you somewhere else if they have further questions I'm sure you'd be quite happy for that I just have to say thank you very much for a very, very, very interesting session we knew this one was going to be a really good session anyway thank you so much so I just need to