Sunday, March 16, 2008

THE ‘B’ WORD

Breech. A woman today whose baby is discovered to be presenting bottom or feet first (breech) will often be given no other option than elective caesarean.

The evidence that is used in directing mothers with breech babies at Term into the operating theatres was produced in a big multi-centre randomised controlled trial. It’s the most reliable type of quantitative evidence that is available. The research concluded that it’s safer for the baby to be surgically delivered than to be born vaginally.

There are several compelling reasons why I and some other midwives and medical practitioners are reluctant to submit to the breech-caesarean rule. We know that many babies in the past were born safely feet-first, and we know that many women have a strong preference for natural, non-surgical birthing options. We know that some breech presentations in advanced spontaneous labour will be undiagnosed, and that the skill of the midwife in attendance could be a deciding factor in the safety of that baby. The unintended and unfortunate reality of a professional terrain in which vaginal breech births are rarely seen is the de-skilling of the professions.

Another consideration that I will try to briefly outline here is the fact that a randomised controlled trial cannot truly reflect likely outcomes for women who want to work, undisturbed and unmedicated, with the power of their own bodies. So, even though I cannot challenge the results of the Term Breech Trial for the people who were involved, I consider that the very fact that pregnant participants agreed to be randomised into either the ‘labour’ or the ‘elective caesarean’ groups prevented them from engaging with their own natural resources needed for giving birth themselves.

The women enlisted in a randomised controlled trial are treated as though they have a medical condition, and the trial looks at different options for treatment. The hospitals and the maternity professionals who participated in the research could not have been committed to protecting and promoting wellness in childbirth, and many may have lacked the skills of midwifery in protecting natural birthing, particularly in breech vaginal birth. The results cannot apply to women who want to work with the wonderfully powerful natural processes in birthing their babies, as these women would have refused to be enlisted in the research.

Perhaps writing for my blog gives me an unrealistic sense of my own authority. This medium allows me to declare my opinion for the world to hear.

I have two birth stories to illustrate my current practice in relation to breech births.

‘Megan’ was about 39 weeks, carrying her second baby, when she became aware of a hard round lump under her rib cage. She found herself rubbing it from time to time, and thought it might be her baby’s head. She went to the Birth Centre for a checkup, and asked the midwife if she thought the baby might be presenting as breech. The midwife wasn’t sure, and called a more experienced midwife, who palpated and told Megan she was pretty sure the head was down. Megan phoned me a few days later to get my opinion. I visited her, and agreed with her - breech. The presenting part was not engaged, and moved easily. I encouraged Megan to seek ways of turning her baby, and to ask the hospital to attempt external cephalic version. She had an acupuncturist who she trusted, and suggested that she would ask for some acupuncture and moxibustion.

Megan went back to the Birth Centre, and this time the breech presentation was confirmed. She was told that she would no longer be able to keep her booking at the Birth Centre, as she would be booked for elective caesarean. She was already close to her due date, so an appointment was made with an obstetrician.

Megan asked if the baby could be turned. The midwife phoned a doctor at the hospital, who is involved in a trial of external cephalic version (ECV). The doctor said it was too late – the pregnancy was too advanced for her to try.

Megan was disappointed, and told me that she would rather plan a vaginal breech birth at home than have an elective caesarean. I agreed that that was a reasonable backup plan. Having palpated Megan’s abdomen, and felt how readily the baby’s bottom moved, I encouraged her to persevere with the quest for ECV. She made an appointment with the doctor who does ECVs. Megan is quite small and timid, but I admired her strength in this whole process. I encouraged her to go to the hospital with her partner, and ask the doctor to put her hands on her belly and feel her baby. If the doctor then said she could not attempt an ECV, then she would have to accept it and move on.

The doctor did agree to the ECV; the baby turned easily, and after monitoring Megan and her partner went home. Megan gave birth spontaneously to a healthy baby girl who came out head first, a couple of days later.

The lesson I learnt was to persevere. The hospital maternity care system may not automatically provide the options that the woman wants, particularly when those options are in supporting and protecting normal birth. But a woman is quite within her rights to request the sort of help that Megan received, even if that help is not readily available.

The second breech birth story does not have a happy ending. I learnt about this birth when I was asked to review the case on behalf of a law firm in Melbourne, and provide a report on the role of the midwives who provide care.

The mother arrived at a private hospital in strong labour with her second child, and was admitted by a midwife. The mother did not know her baby’s presentation was breech, as her doctor had checked her a couple of days ago and told her the head was presenting. Shortly after arrival the mother felt an urge to push, and the midwife arranged for the doctor to be called to attend for the birth. Before the doctor arrived the waters broke and baby’s legs and bottom were born. The baby’s body was initially pink, but after a few minutes the cord pulsation ceased and the baby became white. The midwives did what they could for the mother, but they did not have the skill or confidence to attempt to deliver the baby’s head. The doctor arrived and the baby’s head was born with assistance, followed immediately by the placenta which had probably separated at the time when cord pulsation ceased. The baby was resuscitated, and transferred to a neonatal intensive care unit. The baby’s brain had been damaged, and the lawyers were now acting on behalf of the child in suing the hospital and the doctor.

The question that was put to me was, should a midwife have been able to assist the birth of this baby?

This tragedy happened as a result of de-skilling of midwives. Today’s new midwives and obstetricians will possibly have had little or no experience in breech vaginal births, and this scenario is likely to be repeated from time to time.

When a baby's presentation is breech, the partnership between the mother and her midwife is put to the test. Various decision points are reached, and sometimes as in Megan's case, the baby can be turned and proceed to a normal cephalic birth. Such choices were not available for the second mother, because the breech presentation was not known until the birth was underway. Any midwife reading this story will do well to review the principles of an assisted birth of the after-coming head; a manoeuver that could have prevented the hypoxic brain damage to this baby.

2 comments:

Juniper said...

Joy, I love reading your blog!

This topic is close to my heart, having had an undiagnosed breech at home last August.

I am *terribly* worried about the de-skilling of midwives in the area of breech birth. I was *so* grateful that those attending my birth were experienced with natural breech birth.

I am so concerned that by having so few women give birth to breech babies naturally, we are giving less and less midwives the opportunity to learn and experience natural breech birth. What does the future hold for women like me?

It makes me cry to read about the second baby in your post - how it could have been prevented, how that could have been me had I birthed in hospital. Something inside must have told me early on that I should chose my care providers very carefully this time around...

Also, the stress involved for women who *know* that their baby is breech in advance must be great. To think that a lot of women just take it for granted that they *must* have a c/section because of breech presentation is sad.

Sigh... thanks for writing about this Joy, and all I can hope is that those of you who are experienced midwives can pass on your skills and knowlede and experiece of breech birth to your "apprentices" for the safety of women in the future.

motherwho said...

Hi Joy, thanks for writing this post! I enjoy reading your blog although this is my first comment.

My second baby was born last month (in Melbourne). My midwife first detected she was presenting breech at 29 weeks which was not a concern at the time, but as the weeks went on she stayed in the same position. At 36 and a bit weeks after much stress, acupuncture, moxibustion, massage, swimming, hypno-tracks, spinning babies.com, etc, etc, the little bub was still breech.

The hospital I had a [back up] booking at were most likely only giving me the option of an 'elective' caesarean (not really elective when it is the only option you are given?), so we went to another hospital and had a successful ECV. I went into labour spontaneously and had my baby girl at home last month.

I feel so lucky to have escaped the knife and terrified that it seemed to be the only option, had my baby remained breech, as we had decided we would prefer not to go ahead with our plan for a homebirth if she stayed in that position.

I still feel confused about the system we had to navigate and realise that if we had have been less educated we would not have questioned it. I can only imagine my recovery and the distress I would have felt now with a 5 week old baby and a toddler running around had things have been different.

My youngest sister is now a graduate midwife and I don't think she has ever seen a vaginal breech birth, nor has she been taught how to support a woman/baby should one arise under her care.

Definitely cause for great concern, in my opinion.