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.

an observation of a placenta's healing property

Those who have been reading my blogs over the years probably realise that a great deal of what I write comes out of reflection on actual recent experiences in my midwifery practice.  Today I want to write about a placenta.

As I sit down at the computer I am conscious of my weariness, overlaid with the 'buzz' of good cup of coffee that I have just consumed.  I was called out at midnight last night; the baby was born at about 2:30; and I returned to my bed for a few hours at about 6:30.  I accept this weariness and irregular sleep pattern that comes with the territory, and my heart is content and thankful to God the creator of life, because once again I have witnessed the awesome yet unremarkable event of a healthy woman giving birth to a healthy baby.

I have headed this post 'an observation of a placenta's healing property'.  That's what I think I observed, and will try to document here.

Last week I attended another spontaneous birth at home.  Uncomplicated; great 'outcomes'.  But there was one unusual feature that set my reflective mind in action: a considerable amount of fresh bleeding during the labour.  I have estimated 50-100ml in total, which is considerably more than a bloody show.  It would be classed an antepartum haemorrhage (APH).  The show usually comes from the cervix, while this APH must have come from the placenta. 

Anyone who is familiar with my midwifery practice will probably ask, how did this baby come to be born at home?  If the woman was having an abnormal blood loss, is that not an indication for transfer to hospital, continuous electronic fetal monitoring, and closely managed obstetric care?

Yes.  That is what would usually happen. 

The realisation of what had just happened only settled in on my mind after the baby had been born, when I went to the bathroom and saw a collection of blood-stained toilet paper not yet flushed away.  When I spoke with the mother about it she confirmed that there had been a significant amount of bleeding through the labour.  By the time I arrived, and she was ready to get into the birth pool, already feeling a strong urge to push, there was no bleeding; the fetal heart sounds were good; so we proceeded with the birth.

The second realisation that I had in this case was when I took the placenta to the kitchen sink, and checked it under the bright light (rather than the dull light of the birthing area). 

The placenta was complete, with no unusual features.  However the membranes were clearly torn into the placenta at one edge.  The interesting observation I made was that the torn edges of the membranes, for 2-3 cm from the edge of the placenta, appeared to have shrunk slightly as though an astringent had caused them to pucker.  [I wish I had taken a photo of this, but I didn't, so words will have to suffice].

Ummm.  Interesting, I thought, and completed my check of the placenta, placed it in the bowl provided by the mother, and went on with my work.

I had not previously observed this phenomenon that I have described as astringent, or drawing together of the tissue.  But as I turned it over in my mind, this is what I have wondered.  The bleeding obviously came from the point at the placental edge where the membranes had torn.  The bleeding did not compromise either mother or baby's condition.  There appears to have been something that had an astringent effect on the torn part of the placenta and membrane, that worked to heal the tear and reduce blood flow.  That is what I mean by the placenta's healing property.

bleeding after birth

Today I am reflecting on experiences I have had with post partum haemorrhage, linking those clinical scenarios to my body of knowledge, reading reliable references that relate to appropriate interventions and drugs to treat bleeding, and applying learning to my practice.


The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).

The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers.  The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm.  An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO).  The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.

Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony.

Recently released 3 Centres Guidelines, confirm the practice:

Active management of the third stage of labour is recommended practice worldwide, with an anticipated completion period of 30 minutes.

Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth.  I do not fear the third stage.  If that were the case I would not be suitable to continue in the work that I do.


The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage.  The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time. 

Midwives around the world work this way.  This is alluded to in a statement on physiological management of third stage  released by ICM in 2008 and reviewed in 2011.

The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).

At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted.  Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ... 

Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels.  Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy.  Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures.  Women may be overweight, or poorly nourished.  Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth.  ... and so on!

So, you may ask, what's the problem?  What causes uterine atony in an otherwise uncomplicated situation?  Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?

I won't attempt to give a text book answer here.  I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation.  You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.

I have looked through my birth register.  In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls.   I remember these women, and the setting of birth.  I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.

The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.

"Western practices neither facilitate the production of a mother’s own oxytocin nor direct attention to reducing catecholamine levels in the minutes after birth, both of which can be expected to physiologically improve the new mother’s contractions and therefore reduce her blood loss."

  Dr Sarah J Buckley 2009 (page 179)

This topic will be continued here.

 

The midwife

I have been enjoying the BBC series 'Call the Midwife', which has been shown on Australian ABC TV.  This week we will see the fifth and final episode in the series.

(If you go to You Tube you can apparently download and watch the full first series.)

Since I began writing my stories in the mid 1990s, in The Midwife's Journal,  I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested.  The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.

Last week I wrote about women's rights in childbearing.  This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife.  The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.

Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.

Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young.  Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.

A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few.  They may follow pregnancy-birth related social media groups and forums.  She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.

I said it's a potentially overwhelming burden of knowledge about aspects of birth.  I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try.  I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax.  I wonder where he obtained this knowledge.  I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.

One mother who gave birth about a week ago had confidence.  I have been with her for several of her babies.  She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze.  Her preparation for birth included good food, adequate rest, and work about her home.

As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet.  I rested on the couch.  Then she invited me into her bedroom: "it won't be long now," she told me.

Quietly and steadily she guided her baby down and out.  There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it.  Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation.  The third stage proceeded without the need for any medical intervention, and there was minimal blood loss.  When I visited this mother she was sitting outside in the gentle spring sunshine.  I saw a well mother, with a well baby at her breast. 


In telling this story I have not mentioned the buzz word of the day: collaboration.  Those in authority today will insist that collaboration is the key to safe maternity care.

Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees.  The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications.  This is basic midwifery.  The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.


Thankyou for your comments.

Women's rights in childbearing

I took a consultation paper on birth registration, and the latest issue of MIDIRS with me in the plane yesterday.  The flight from Melbourne to Brisbane takes about two hours, which fits well with my capacity to stay focused on a topic. 

The issues around women's rights in childbearing have been promoted by many writers and film makers.  A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to  criminal proceedings against doctor-midwife Agnes Gereb.

Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.

Who decides how and where a baby is born? Who bears the risks of childbirth? What legal rights do women have to choose how they give birth? These are just a few of the issues that will be discussed at the upcoming Childbirth and Law Forum on Friday 12 October 2012 at Riverside Theatre, Parramatta.

The Childbirth and Law Forum will begin at 2pm with presentations from  two speakers who will discuss the legal issues facing childbirth today in Australia. (Homebirth Australia press release)

It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system.  Barrister Elizabeth Prochaska wrote:

A recent case of mine shows that it is worth fighting decisions to refuse to provide a home birth (even at a late stage in pregnancy).  A large London hospital suspended its home birth service for a month due to staff shortages and informed women who had planned home births that they would be transferred to hospital by ambulance regardless of whether or not they consented to transfer.  AIMS put a coupe in contact with me who had been promised a home birth by the hospital.  With only a few weeks before their baby was due, they decided to threaten legal action, relying on a legitimate expectation and the Ternovsky case. The hospital rapidly backed down and agreed to provide independent midwives to attend all the affected women at home. (Prochaska E. AIMS Journal, vol 24, no2, 2012, pp6-7.)

The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care.  Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth.  For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth.  Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.

In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them.  They are no longer 'low risk'.

Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate.  A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance.  The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be). 

Midwifery services today use the term 'evidence based' without challenge.  The exclusion of women from birth centres and homebirth programs is considered 'evidence based'.  Rarely does anyone ask, "what evidence is that?"

A recent update of the Cochrane review , the centre of excellence in medical evidence, states:

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. ...

Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women

Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. [emphasis added] In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. 

An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards.  Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.

In 'Women's rights in childbearing'  (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth.  The article reports that  UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."

Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present.  The limits of responsibility in such a situation are in no way defined or clear.  It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife.  Unfortunately it will take adverse outcomes to test the limits of women's rights.