 We'll first introduce Latta. So Latta Balasundaram is a lead physiotherapist at Fernandez Foundation in Hyderabad, India. She has a master's degree in physical therapy in pediatric and adult neurology, but over the years developed a passion in the area of women's health. She's also a Lamas certified childbirth educator and a lactation counselor. Coming from a country where cesarean section rates and unnecessary medical intervention rates are high, she feels strongly about educating, expecting couples with information that could help them make informed decisions in their birthing process. Over the last 14 years of clinical work experience, she has worked with helping women with pain, optimal fetal position techniques in mal-positioned babies, alternate birth positions for women with muscle skeletal issues and pelvic floor rehabilitation in women dealing with pain and incontinence. She works passionately in these areas with the hope of helping and empowering women on their journey leading to pregnancy birth and beyond. So Latta, I am going to hand over to you now, the controls so that you can begin your presentation. You should be able to... Yes, thank you, Latta. Welcome, Latta. Take it away. Thanks, Red, for that introduction and it's a pleasure to be on this platform of the IDM today. I also would like to wish all the midwives a happy international day of midwife. And coming straight to my topic today, I'll be presenting about the success of implementing exercises in turning beach babies and increasing normal vaginal birth rates. Yes, so my aims and objectives. This study has two primary objectives. One is to check the impact of optimal people positioning exercises on beach presentation. And the second being to see the incidence of normal vaginal birth rates in women whose babies have successfully turned. The background in India, particularly and also everywhere else, up to primarily after the beach trial 2000, plans of the hidden sections really have become the model for women who presented with beach. And before we actually set this pathway up in Fernandez Hospital, the women who came to us were offered external septic washing and if failed, then they were offered the Cezarean section. But all public hospitals and public institutions in India, 100% rates of Cezarean sections because that was the only option given to women presenting with beach at term. Now, as we know, we do have a lot of contributing factors to buy, sorry, we did start the structure pathway primarily in 2018 February after Tammy Ryan, the trainer for spinning babies, came and did a wonderful three-day workshop and opened up this entire world of spinning babies and optimal people positioning for us. We were a group of mixed physiotherapists, childbirth educators, doulas, myth bites and obstetricians who actually took part from all over India who came for this three-day workshop. The philosophy of a lot of reference goes to spinning babies and therefore the philosophy of spinning babies is actually balancing the soft tissues of the body by using gravity and specific movements to enable the uterus to align better for optimal people positioning and also easier labor. So we learned techniques in pregnancy as well as in the interpartum phase. Then we came up from March 2018 into this structured protocol which if a mom presents with Breach at 32 weeks scan, then she's offered the spinning babies exercise techniques if she does and body balance techniques. If she does accept, then we recheck the presentation at 37 weeks and if the baby has done, then regular antenatal care is provided to this mother and she has a trial for her mom with our children. And if this mom's baby does not choose to turn and continues to remain in Breach, then she is counseled for external catholic version. And the women who accept external catholic version and are successful in that, again, go ahead in having regular antenatal care and try for vaginal birth and the unsuccessful ones along with the ones who decline ECBs are both counseled for Breach vaginal births and C-sections. So this was the pathway we followed. The methodology being a retrospective analysis of 340 mothers taken from March 2018 to December 2020. We did have very clear inclusion criteria being singleton fetus and any pre-presentation between 32 weeks up to 37 weeks gestation booked with us. We did have very defined exclusion criteria since we have a wide spectrum of mothers from low risk to high risk coming to us and we wanted it to be safe. We did exclude these 10 criteria that you can see. We also did not include any twin pregnancies in this. Now coming to the results, the first thing is to see the success of the exercises that we did. Since we did have an entire year, a little over a year of pandemic, we did lose around 12 of them, which around 3% of them lost to follow-up since some of them decided to birth at their own place in their hometowns so that was lost there. But 62% of them, that is 211 babies turned Catholic and the remaining 35% remained in Breach. Now from all the 211 who turned into Catholic, we had 53% 111 going on to have a normal vaginal birth and the ones who did not set into labor, lot of them declined and requested for a C-section. This came up to around 17% of them. This was because of failed inductions or not consenting for induction. And 22% which is 35 of them went on to have an emergency C-section for presumed fetal compromise. We also did offer ECVs for the ones who continued to remain in Breach, 14 of them accepted, seven of them successfully had ECVs and went on to have a trial for vaginal births. The ones who didn't, which is seven of them, five accepted and consented for Breach vaginal births and three went ahead to have success with Breach vaginal births. Now, as already discussed from the term Breach trial, like hundred C-section sections are the only option in public health sectors in India. And even in the private health sectors, very few really, absolutely very few offer ECVs or any specific exercises as a structured program. They have many contributing factors to Breach positioning that can influence Breach positioning and which could be external or internal, but we are not gonna talk about the internal factors that we really have more control over. We are going to talk in a little more detail about the soft tissue surrounding and supporting the uterus. And when you come to the soft tissue surrounding the uterus, we do have primarily these ligaments that we talk about which are the broad ligament which completely comes from the natural walls and goes into the center of the uterus. It does support the entire weight anteriorly of the uterus. We do talk about the uterus sacral ligaments which inserts into the sacrum and also the round ligament which supports the uterus going through the inguinal canal into the mons pubis and labia. So these are primarily the ligaments which surround and support the uterus that we actually work on through what we see in our exercises. These are some of the muscles, the major group of muscles which influence the symmetry of the pelvis, therefore influencing the fetal position. You're looking at this orange muscle which is a very important source muscle coming and inserting into the hip and this almost literally swaddles the uterus. You also have the quadratus lumborum which attaches or connects the posterior superior and iliac crest and the lower ribs. And you also have the green muscle as you can see which is the pelvic floor muscles which support it inferiorly. You do have the small triangular muscle which we call piriformis muscle which contributes a lot to the hip and pelvic mobility. And when you look at all these muscles they are connecting the spine, the pelvis, the hip and therefore any asymmetry in the left to right or any type, excessive tightness, phasom, twisting, triggers all of this can cause asymmetry in the pelvis which again influences the way the uterus actually lies. And here is another image just showing how beautifully the muscles and the ligaments are intertwined and how they form this entire support in structure to the uterus. Importance of body balance is very important to understand here since we've designed the structure based on this. As you can see here you've got a perfectly balanced and square pelvis and you do have a proximal and distal joints which are also very well balanced. When you look at the pelvis here it is not symmetrical and you can see how it influences the spine to curve how the proximal joints have asymmetry and also the distal joints have asymmetry. So this just goes to say when you want to work and you want to work on a better outcome you just don't work on just the pelvis but the body as a whole it would be nice to look at the body as a whole since it is a closed kinematic chain complex. So very early like from 16 weeks onwards we encourage as many of mothers that come to us to enroll in our regular antenatal classes our childbirth education classes out of which they do practice these body balance exercises and we just look at comfort and your body balance and better biomechanics and better postural corrections, things like that. And here we just addressing the calf muscle the hamstring muscle, the back muscle, the chest muscle just some simple exercises that they do. They do come in with their partners and here you can see our classes where they are exercising with their very involved and interested partners. We do also have importance is given also not just on flexibility or yoga but a strength and flexibility balance as you can see the mums first image they are stretching out second image they are strengthening. We do have these mums not just like I said flexibility but some tone important muscles that need strength are the gluteal muscles and you can see the core muscles which we also address and work on in our group classes. Coming to now though we do expect all these women to come as early as possible be interested in exercise, be more aware, all of that but we don't get all of them coming in and that is why let's say they do come to us at around 32 weeks with a rich presentation then we do take some of the body balance exercises which are focused on the primary muscles which as you can see the first image is the suaas muscle being stretched. The second is the adductor and the hip muscle being stretched, the rotators. Here you see the spine increased mobility exercises. This is commonly called the caten cow and it is amazing to improve the symmetry of the spine and the pelvic mobility along with strengthening the core as well. So we include these four exercises if they do come in at 32 weeks and have no clue about exercises because if you give them these entire list they've never come earlier to do it very likely that they may not be compliant to all the exercises we give them. So to ensure that we keep it short and limited we give them these four and then from the spinning babies we do give them the three sisters of balance. Now what are the three sisters of balance? The three sisters of balance are one of the abdominal shifting exercise and I'll tell you how this is relevant. You'll be used at the gozo and we encircle entirely the abdomen we lift it gently up and use small shifting hand motions almost like a micro massage effect. It gives to the broad ligament that we just looked at amongst the ligaments supporting the uterus and the entire abdominal fascia as such. You know when you have a woman on her feet all day and let's say that uterus is tilted anteriorly a lot more you'll know that the broad ligament gets strained and tight and this can cause pain. A lot of times in women abdominal lateral pains as well as decreased pain can be a reason why they can be spasm and again decreased room for the baby. So we just address that with abdominal shifting. It is very relaxing for the mother. You do have forward lean inversions it's done in three steps. The first and the last is this kneeling position and the middle one is head down. Now this uses two philosophies one is the use of gravity. The gravity acts on the heaviest part of the baby which is the head and the spine therefore easily turning the baby around giving more chance for the baby to flip around. And when you come back into this position it repositions that Pupus sacral and Pupus cervical ligaments that we see which can become tight and twisted and influence the way that of the uterus. Therefore when you untwist this and make more room in the lower part it realigns the uterus when you come back into kneeling position. So this is the two ways it works. And then you also have the sideline release it's not just about lying onto the side but it is a lot to do with stacking the hips, stacking the pelvis, the shoulders, the lower leg locking it in dorsiflexion and they're just dropping the top leg down to relax. It works largely on the perineal area and the lateral hip musculature. Also it's very soothing for moms who have perineal pains due to tightness moms who sit who have sitting jobs who recline and sit who are not very aware of their posture. There is a lot of perineal tightness present there as well. So this is something which is excellent for those moms. So if you look at those four body balance and these three sisters of balance you know that the crucial room makers that we are looking at are the soas muscle, the dorsal lumbar musculature, the broad ligament of course, the round ligament, the Pupus cervical and the uterus cervical ligaments and inferiorly the pelvic floor. These are definitely the primary contributors. So when a mother walks in, it's just a quick view of how the mother is walking. First you know, is she walking with the anterior tilt? Is she walking with the posterior tilt? Is she walking wide-based and like a duck? All this gives us an insight of what to work on because then you know that the gluteal muscle is important to strengthen, it's weak or the abdominal muscle or the core is weak or there's severe tightness in the hamstring. So this generally gives us that idea. Then we go ahead to check that by checking the muscle length and like I already said, a good balance of the strength and flexibility. So it's important also to reconfirm that assessment of posture by checking the strength of the muscles. And when you do have any asymmetry caused like the level of the shoulders, the alignment of the spine, the level of the hips, this also goes, should not go unaddressed. And sometimes a mum can come with severe scoliosis or a limb length discrepancy where we do have to give some footwear modification. So this is also important to address. Now pain is a huge contributing factor to decreased room for the baby and particular postures. Definitely the room makers we talked about are largely influenced by pain because the piriformis muscle or the sacro tubular sligament that we talked about or the perineal muscles when they are in pain and the lower back, the quadratus lumborum muscle when they are too much in pain, it forms spasm and contracts pulling the pelvis and the spine in different positions of asymmetry. Sometimes when you simply work with relaxing those muscles with soft tissue release with your hands and some heat, it just relaxes them and creates a lot more room and your outcome to your exercises is a lot better. We also have to train the mother on how sensitive she is to the position and the movements of the baby. So we just try to educate her on, if you have small cluttering movements, it could be the hands, if you had cross movements, it could be more of the limbs and if you have a bulge which is movable, it's the head, if it's not, it is the bum and on the left and right side of the abdomen, if you have a little bit of the bulge which is more on one side, it could be the spine of the baby. Things like that where the mom knows and she's sensitive that, yes, my baby is moving a lot more now and she's positive that the baby will spontaneously get into the position of head down soon. It is also very, very important. See, she may be exercising just for 15 minutes or 20 minutes at the max or half an hour, but when you look at her everyday activities, if she's a mom who's sitting in a chair in the desk job or if she's a mom who needed to constantly be on her feet and these kind of things, if she's not having symmetry in that and if she, let's say, reclines in a recliner most of the day if she's at home, then your carryover of the exercises is not that effective. Therefore, we do need to consider what her everyday activities and occupation is to just give her good postural advice. If you have a mom who's reclining most of the time, she's definitely gonna have a lot more perennial tightness. You want to give her some forward lean positions that will enhance the baby to be in a better fetal position. Simple examples of what we could do just as an advisory for the mother. Therefore, just covering up what we just talked about, as early as possible to encourage these moms into body balance exercises from 16-week converts. If they don't or if they are not compliant or still do come with babies in bridge, after 32 weeks or so, anytime between 30 to 37, we give them a few of the body balance and the three sisters of balance. We also give them activity modification advice on economics and occupation and their everyday activity. Therefore, the conclusion is that we do recommend offering specific exercises for automated positioning to help these big bridge babies turn. And also, as we can see, we did have 62% success rates. We did also introduce, by introducing these structural exercises, we definitely have reduced the rate of cesarean sections for bridge presentation by 53%. In general public hospitals, it is where it is 100%. So this is the conclusion. And these are some of the references. Spinning babies being a big reference, we do also have some references for bridge positioning and what influences it, as well as a lot of detail into the biomechanics of the pelvis, the anatomy of the abdomen of the pelvic in net and outlet, and positions for labor and birth. And also how ribosal techniques can influence fetal positioning. And thank you so much. I am here for questions. Over to you, Red. Thank you. What a wonderful presentation. Lot that we can really see how well you prepared and also how well you know the subject matter. So it's just being a little bit familiar with Fernanda's hospital there in Hyderabad myself. I just see that it's so, so wonderful that you are really empowering the women there with these exercises where they can take charge of their situation a little bit prenatally and also to see the belly mapping that you're doing. So also teaching them how to palpate and understand where their position, the baby is positioned in their body. It's just such wonderful empowering work that you're doing there. So congratulations. And yeah, so we can take, we have some time we to take some questions from the audience. So please feel free to type. Let's go up to the top and see if we missed anything up here. There are some people here in the presentation including Catherine who's hearing about spinning babies for the first time. So that's really wonderful. I can see for myself as a midwife, it's really been an absolute game changer in my practice to have an understanding of these ligaments of these muscles, how they affect babies positioning and to be able to empower our mamas with the information. Beautiful pictures. Let's see, such informed work to help with muscle relaxation towards physiological birth. Okay, so people are amazed by your work and your presentation, it seems like. It's great to see that you also have, I know Fernandez is such a busy hospital there that you were able to get such a great number in your studies at 340 women. That's really awesome. And those success rates of 62% of turning that's also really, really interesting to see. I did have a question about are all the midwives there trained in understanding these techniques or is it usually that like for yourself the physiotherapists come in for this part? We did have three of our midwives as a part of this training program. And then when we came up to the structure of a program from the physiotherapy aspect, we did tell them about the quick things to assess. And if they have any more queries, we are always available in the hospital. So they give us a quick call saying that can you do a detailed assessment? I feel there's something which I'm missing and then we are there. But yes, three of the four of our midwives in fact are also trained and we have them across our units. So in every unit we have one midwife who is trained with spilling babies. And yes, they are as aware as what I just talked about. Okay, yeah, this is great. And I was also curious, I wasn't sure from your presentation, you said you started from about 32 weeks. I was wondering are generally all the moms who are coming there, are they educated with the three sisters of balance and the different balancing exercises to do or is it specifically the information just given to those who have a breech baby at 32 weeks? No, it's the three sisters of balance is specific to a baby who comes in with, a mother who comes in with breech. But the body balance exercises that I talked about from 16 weeks onwards, that is given to most for our general group sessions for months, with or without breech, yeah. That's great to see, amazing. And do you find that there's a good success rate in the moms who are also taking that responsibility and like doing the exercises at home? Yes, definitely, I feel the more compliant, the more belief they have in what they do, I think we have seen, we can't really say just because of that. Sometimes we just have to say, well, your baby doesn't want to turn and we have to accept that if your baby doesn't. Yeah, but there's better compliance is definitely a better outcome and better carry over to the exercises. Being constantly aware of our posture is one of the huge contributing factors to also how the baby has room and opportunity to turn. Yes. We have a question here. I hope that I pronounce this right. Bonsane Bonsiano. She's asking the assessment maneuvers, including your recommendation. What considerations do we have for mothers with physical disabilities? So yes, we do have some mothers who come in with physical disabilities and with their rich babies. So yes, here definitely a physiotherapist would have to see this mother to assess the body better. The considerations that we have is, so far we have seen mothers with severe structural scoliosis for sure. We have seen mothers with, you know, heavy parishes, like, you know, maybe they had a mild form of a parishes on one side of the body and that causes a lot of imbalance. So then if that's why these mothers with the history of this are referred to us early, then we work on actually building that symmetry as much as we can, and then which would give the baby more opportunity to turn. So the considerations would be definitely early recommendation for a visit for assessment and also working on this mother to as far as possible, you know, if it's structural, we can only work on the soft tissue. We can't manipulate the bones in pregnancy, definitely. We don't usually encourage to do that. So these are the two considerations we would give the men with specific physical disabilities. We also give a lot of alternate birthing positions for these mothers with physical disabilities so that they do have a trial for vaginal birth and not just going for the C-section because they had polio or because they have some other physical disability. This is really informative. Thank you. Any other questions for Latta? We have a few minutes remaining. Don't be shy. Curious to hear in the chat how many midwives out there are currently using these spinning babies techniques. Is this something that you use in your practice? Is it being used in your setting? Or is this the first time you're hearing about this? You know, for me, like I said, it's been a real, it's definitely been a real game changer to just be able to understand more about the ligaments and the muscles and how everything works together and how we can really avoid, help women to avoid those C-sections for breach. We do also use them a lot in birth, in birth. Oh, yeah, nice. Yeah, so that's interesting. It's wonderful to see how it works actually with the OP baby, for example, or some other who's having engagement issues that we do see or a slow labor. We really love to use them. That's an interesting question. That's an important ad. Thank you for adding that in. I see that as well, even for changing, shifting a baby from posterior to anterior. There's so many ways that we can use these exercises to help baby to get in that really optimal positioning. Anne-Marie is saying we use three sisters of balance as well as yoga in our birth center in India and also the ECV. That was one question. I'm not sure if you can answer this, Latta, but I was just curious about for the ECVs there in your setting, is it the midwives that are performing them or is it the obstetricians who perform the ECVs? A little bit off topic. The obstetricians perform the ECVs, right? There are a few obstetricians who train and attend who perform it. Right, okay, got it. That's great. Well, it looks like maybe we are at a conclusion here. So last chance, any one of you want to chime in here with Latta, with a question or to share your experience. And otherwise, thank you so much, Latta, for sharing your time with us. It's so nice to see how progressive Fernandez Hospital is that they also have you, for example, a physiotherapist on board on the team to really help optimize the experience for mamas and babies there. So that's so wonderful to see it happening. And of course, we know that in India there, you are all in quite a epicenter right now also with COVID. So we just want to just know that all of us around the world are sending you so much love and good health as well there. And we hope you move through this very quickly there.