Thursday, December 06, 2012

why breech births are important

I had a moment of clarity just the other day: Women who have breech babies, and for whom spontaneous vaginal breech birth (vbb) is an option, need MIDWIVES who are willing to be on call, and work with them to the full extent of midwifery as primary maternity care providers in their births.

But, I hear someone say, midwives have been deskilled in VBB,  Most breech babies in the past 20 years have been delivered by caesarean.  So how can a midwife consider herself competent?

And, I hear someone else say, surely the hospitals won't allow a midwife to 'manage' a breech birth.  Surely the senior obstetricians will take control?

Yes, these are valid points, but there's one other point - the point of my recent epiphany - that needs to be considered.  No matter how deskilled midwives and doctors are, the woman's body is, in many cases, ABLE to do the work.  Spontaneous birth, regardless of which pole is presenting, is just that: SPONTANEOUS.  Spontaneous means that the progress happens under the powers that are within the woman's body.

I don't want to sound ignorant or naive here, because I know there are specific complications with breech births that increase risk of neonatal morbidity.  An arm can impede progress: a midwife can manipulate the baby to free that arm.   A baby can be born with low Apgar scores: a midwife is able to provide resuscitation.   The knowledge that upright vbb works well has been circulated in midwifery circles for as long as I can remember.  I don't know when I first heard the old adages, "let the breech hang" and "hands off the breech".  One of the main questions in the exam I took in 1973, when I became a midwife, was all about breech births.  Yet the obstetric textbooks teach the lithotomy position; and the warmed towel to support the baby's body while the various manoeuvres which have the names of obstetricians (eg Lovesett, Mauriceau Smellie Veit ... - I haven't checked the spelling) are performed.

Since the publication of the Hannah (2001) Term Breech Trial, which had the almost immediate effect of channeling almost all breech babies to the operating theatre, midwives in my part of the world have had little experience with vbb.  Breech presentations occur at Term in about 4-5 of 100 births.  In my practice I have seen one or two most years, which is consistent with that rate.  I have followed the current best practice guidelines and sought out external cephalic version, which in at least half of the cases has done the trick.  I would be foolish to claim any special expertise in vbb.  Yet, with the information and drive I now have, I would now be prepared to discuss the option of spontaneous vbb at home in my care, or hospital, with any woman at Term with a breech baby on board. 

There are just a few birthing situations today that potentially challenge the skill, knowledge, and courage of a midwife.  These may be unanticipated.  They may occur with little warning.  And they require the midwife present at the time to act decisively in interests of safety of the mother and/or her baby.

A breech birth can be a big surprise.  The midwife can either act in harmony with the natural processes, and support uncomplicated birth of a healthy baby, or interrupt the processes and mechanisms of birth due to ignorance and fear.

Spontaneous birthing is the terrain in which midwives work best.  We watch and wait, and hold a cocoon of safety around the woman-child unit.  We know the subtle behaviours that indicate progress, and we know how to minimise adrenaline and other fear-related hormones.  We know how to leave well alone; how not to fiddle.  We know how to stay quietly with the woman, physically and emotionally, as she progresses on the pathway to bringing her child into this world.

Spontaneous birthing for vbb must be upheld and protected by midwives and women in all communities.  Sure, some of the big teaching hospitals need to set up breech clinics and have specialists strutting their stuff.  But the reality of childbearing is that women in small towns, and in outer suburbs, and on farms, will also occasionally need to give birth to breech babies.  Many won't have the $15,000 needed for a private hospital booking with the heavily booked breech doctor.  Many won't be within the catchment of the public hospital breech clinic.  They will need a midwife in their community who can work in harmony with a spontaneous and life giving process, and who has the skill to recognise complications in a timely manner and manage referral and transfer of care when it is indicated.

Does anyone out there see what I have seen?

Does anyone else feel deep sorrow for all the breech births for which we have not provided the option of midwifery care?

Midwives who are willing, we need to provide breech education for other midwives, and get the word out in women's groups that breech births can be great births. 

And, btw, we know that the promotion of spontaneous birth for breech babies will not necessarily be easy.  Midwives may need to provide arguments about women making informed choices in professional conduct hearings.   This is the world in which we live.

For more consumer-focused breech information, go to BBANZ

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