BREECH

When I think about breech births the pictures that come to mind are women who I have attended for breech vaginal births, as well as a few other stories that have been preserved in my memory.

There's Sally, who gave birth unassisted to her 'feet first' baby one night in an ambulance.  I had palpated her abdomen that afternoon: head down, very mobile.  When she went to bed she felt a huge movement, and knew that baby had done a forward roll into a breech presentation.  She got up, went to the toilet, and as she sat down her waters broke, a foot and some umbilical cord presented.  Sally kept a cool head, gently put the loop of pulsing cord back into her vagina (to keep it warm), explained what had happened to her husband, who called the ambulance and me.  Sally's first baby had been born by emergency caesarean after finding that he was presenting breech.  Her second baby had been born (cephalic) at home in my care.  This was the third.

The paramedics arrived quickly, and they assisted Sally as she walked to the vehicle, pausing as she laboured strongly.  Sally told me later in detail how she waited for the head to be born, and supported her baby as he took his early breaths.  By the time I connected with them Sally and baby were resting at the nearby hospital emergency room.  After birthing the placenta, we went home again and had a cup of tea, with vegemite toast.

A few others of these mothers have already been written about in this blog.  [Thanks here to the blogger search function!]


In 2007 I wrote generally about vaginal breech birth, and the deskilling of midwives and obstetricians.  I noted that:

 The very real situation that presents itself today is the deskilling of midwives, and of obstetricians, in breech birth. A baby may be harmed or die simply because the midwife or doctor did not know what a more skilled person could have done to achieve the best outcomes.

In 2008 I wrote about The 'B'-Word, and told two breech birth stories, about one whose baby was born at home after ECV, and another mother whose baby developed a serious spastic brain injury from hypoxia, after abruption of the placenta some minutes before the birth.

In 2009 I wrote 'Thinking about vaginal breech births' in the leadup to the screening of a video 'breech in the system'.

In 2011 I wrote about normal birth for a breech baby, reflecting on the work of colleagues in bringing vaginal breech birth to the attention of the maternity professions and public.

In (March) 2012, reflecting on twin and breech births, I wrote about safer and better systems of care:

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001).

Another memorable breech (first twin) birth took place in 2009, and has been noted in the post titled 'Why bother coming here if you won't let us manage you the way we think is best?' 
and the follow-up post 'Drive-through birthing'.


The purpose of today's essay is not just to collect stories, but to assert my belief that we can change, and put effort into making "our systems of care safer and better".  By "our systems of care", I include all aspects of professional maternity care, from the 'village midwife' primary carer, and the bush hospitals, to the big tertiary maternity units.

I believe this is happening.  Women's Healthcare Australasia and the University of New South Wales, Sydney have advertised a program 'Hands off the breech'[click here for speaker' profiles] to be held 30 November and 1 December.  Several of these speakers will be presenting their talks in Melbourne and Warrnambool in Victoria, also in early December - click here for program.  I plan to attend the session hosted by Monash Medical Centre - one of the 'big 3' maternity hospitals in Melbourne, and a strategic place to get the discussion about vaginal breech birth happening.

Social media is active in this regard, and many messages are being posted on a facebook site linked to the Breech Birth ANZ site.

For some, the changes are too little, too late.  Mothers have told me that they agreed to caesarean births for their breech babies because they were afraid.  Fear works against the protective intuitive forces in spontaneous birth.

Mothers have said to me, "Are you willing to attend breech births at home?"  That is a question that I can not give an immediate answer to.  I am committed to doing all in my power to protect the wellbeing and safety of mother and baby.  There are times when a breech birth (or twin) at home could come into that scope.  Other times there will be discussion and the decision may be made to go to hospital.

That's enough from me for today.  Thankyou for your comments.

PS
The following comment was left today (14 Nov 2012) on an earlier post about breech birthing.  I have included it here as it is relevant to the discussion:


motherwho (http://motherwho.wordpress.com/) has left a new comment on your post "THE ‘B’ WORD Breech. A woman today whose baby is...":

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. 

Thankyou 'motherwho' for sharing your journey.

Understanding what's behind an adverse outcome

Today I am recording a few of my personal thoughts in relation to the (lengthy) Coroner's report that was released this past week, in Adelaide.  I have written about it from the perspective of Australian Private Midwives Association (APMA) at the privatemidwives blog.

Principles of accountability and transparency must be applied to professional practice.  When something goes wrong in birth, our society wants to know, and has a right to know what happened.  It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear?  How must I act when a woman in my care understands her personal risk differently from the mainstream?

A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain.  The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity.  So, when I read in the SA Coroner's report that 

"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."

I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?

The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.

This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:

• if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);  
• if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean; 
• if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean) 

That is a superficial, linear argument that fails to recognise the complexities of maternity care.  This suggested course of action ignores the increased risk that each caesarean places on the woman's reproductive future: a risk that does not really show up in the statistical reports.  It passes over the fact that many women who seek private midwifery care are consciously avoiding mainstream services.  It fails to notice that highly skilled, experienced midwives have been excluded from practising in any setting except the home.  And then there are all the issues of trust and continuity in providing optimal maternity care.

I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result.  The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation.  She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]

Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive.  The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives.  The emergency code had been rehearsed, prepared for, and was called into action.  Perhaps that group of midwives will be more ready and competent when it really is called for???

In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety.  I cannot control another person's actions.  I also cannot use these experiences as a reason to stay out of hospital in future situations.  The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.

I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
***********

The Coroner's recommendations are listed at the end of the 106-page report.  In this blog I am attempting to summarise the recommendations, for future reference:


1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

safer and better systems of care

with my first baby 1973

Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.