Doula, master's of public health graduate, new IBCLC, and feminist. I'm reflecting on my studies, reflecting on other people's studies, posting news, telling stories, and inviting discussion on reproductive health from birth control to birth to bra fitting.
An amazing story from a classmate of the student midwife and L&D nurse At Your Cervix:
There are several nurses in the room readying for delivery. I lower the bottom of the bed, glove up and Mary hands me the amniohook. Nice hard vertex presentation, large bulging bag, just a bit of an anterior lip, then AROM, and clear fluid. It was going to be easy. Ana bears down, my fingers still in. But… something is just not quite right, palpate around, what is that at 3 o’clock? Lips? Nope. Ear? No. Scrotom? Yep! I glance over to Mary and in a remarkably calm voice, say:
“Glove up”
“Huh?” says she.
By this time Mary is taking in the rather “unable to ignore” saucer- sized eyes that I’m exhibiting.
Not birth-related, but something that really touched me to see today: Dan Savage's It Gets Better Project: a collection of videos of adults telling gay teenagers that high school ends and their lives will improve. Read an interview with Dan Savage here, including the reason he decided to start this project.
I was talking with a woman recently who had a c-section for her first baby, who was breech. I said something like, "Yeah, almost all breeches are c-sections now, although in Canada they're starting to do them vaginally again." She looked surprised and said, "Really? I thought they COULDN'T be born vaginally. I thought they would be strangled or something."
This woman was totally happy with her c-section, and it seemed like that was the right choice for her. She said she'd even consider a repeat c-section with her next baby, breech or not, so my guess is that given a choice between a vaginal breech and c-section for her first baby, she'd have chosen c-section.
But she didn't choose; what's more she didn't even know she had a choice. She thought her baby could never have come out safely vaginally. I worked with a client last year who found out at 36 weeks that her baby was breech. A doula friend had e-mailed me a series of photos of her friend giving birth to a breech baby, and I pulled them up on my computer just so my client could see with her own eyes: Yes, a baby can be born breech. Before she could investigate vaginal breech more fully (including whether there was anyone who would be willing to deliver her breech in the area), she ended up having a c-section for a combination of issues. Again, it was the right choice in her situation, but in my heart I thought "At least she saw what was possible, and she knew her options". I don't think it's OK for a woman who has a breech baby not to be informed that it is possible for her baby to be born vaginally, and to refer her to more information about that option. Would/could most women travel to find a breech-friendly provider? Probably not, but they can't if they don't even know about it. That's not informed consent.
Rixa at Stand and Deliver has just posted about her first day at the International Breech Conference. It is so wonderful to read about midwives and doctors talking about how to provide safe, skilled breech birth services to their patients. But it doesn't do much if women don't even know those options exist. Spread the word: vaginal breech is possible.
The Society of Obstetricians and Gynecologists of Canada has come out with new guidelines for breech birth, saying that the automatic c-section is not an evidence-based practice and that all breeches should be evaluated and offered vaginal delivery if appropriate. New guidelines are here. I was curious to read through the guidelines, but as I read them I thought “What doctor is going to be willing to go through this checklist when they could just schedule another c-section and be done with it?” That’s why I liked an article that accompanies the published guidelines, by Dr. Andrew Kotaska, called titled, “Breech Birth Can Be Safe, But Is It Worth the Effort?”: (all the emphasis is mine)
Whether term vaginal breech birth is safe is no longer a question. The PREMODA study has clearly shown that with careful selection and management by average maternity units, breech birth can be safe. …
In the PREMODA study, the overall vaginal birth rate was only 23%. Is it important to mount the significant effort required to offer women breech birth if only one quarter will thereby avoid Caesarean section? … In North America, over 100 000 women have pregnancies that remain breech at term annually. With a success rate similar to that of the PREMODA study, some 25 000 could safely avoid Caesarean section.
…[T]he current practice of “not offering” women a trial of labour while providing ready access to Caesarean section is coercive, especially given the equivalency of long-term neonatal outcome. Now, with a more comprehensive understanding of the components required to make short-term outcomes of vaginal breech birth equivalent as well, it would be unethical not to provide this information to women. Although it may be difficult in some settings to offer vaginal breech birth routinely, its availability elsewhere should be disclosed and assistance offered to obtain it if requested. To offer only Caesarean section is ethically and legally difficult to justify if a reasonable alternative is available.
This is really the crux of it, and the guidelines even state that women who refuse a c-section recommendation must still be given care (why does this even need to be said?) Why is it OK to providers to offer one option and not the other? What if no c-sections were offered and all women were required to deliver breech vaginally, regardless of the risks – would anyone be ethically down with that?
I think the next big step is to change the attitude that offering women one choice (to be accurate, no choice at all) is acceptable. After some new evidence came out about Term Breech Trial and other breech trials in 2006, ACOG did a weak “we guess maybe you could try vaginal breech if you REALLY REALLY want to” policy change, and I think everyone would agree it didn’t change much here. The Canadian guidelines, on the other hand, are actual guidelines with specific recommendations on how to safely offer and assist breech deliveries, along with a recommendation to train more providers in breech skills. But without strong advocacy the status quo seems likely to persist there as it does here. Will there be loud enough voices in Canada demanding that those guidelines be applied?
And now hot on the heels of my last breech post comes this fabulous editorial from an Australian newspaper by a woman who asks, among other things, two very important questions:
1) Why do people admire men who climb mountains, but scorn women who have unmedicated births?
2) Why is it so hard to find someone to deliver a breech baby?
I admire her for asking questions and seeking out providers who can give her a second opinion on breech delivery, and I hope she writes again to talk about how her baby's birth goes. I hope many women read this and start asking more questions.
The topic of breech presentation has been coming up for me lately from a few different venues! Someone asked me today what I would do if I had to make the choices of whether to attempt an external cephalic version to turn the baby, whether to schedule a c-section. I know that I would avail myself of acupuncture, chiropractic techniques, somersaults in the pool...every gentle way I could think of to turn the baby! I would have to weigh the risks and benefits of a version, as I would of a c-section.
One of the challenges I would be weighing, though, is how hard it can be to search and fight for the right to vaginal delivery for breech. Even in New York City, where I used to live, doulas would trade around the precious names of the few doctors who did breech deliveries. That's in a city of millions! Upstate, I knew a woman whose midwife wouldn't deliver her breech at home, but helped her find a doctor who would. He was from an African country, and thought breech was perfectly normal. He was happy to deliver her breech baby as he had many other babies in his own country. But you have to be hardworking and lucky to find a practitioner who is experienced with, and willing to do, a breech birth.
And finding a practitioner, of course, depends on you knowing and feeling confident that a breech birth is even possible. I absolutely believe that many people - even those carrying breech babies - do not know that vaginal birth and breech are not mutually incompatible.
Thinking about all this, I started rummaging around on the internets for breech info. I came across this video, and was struck by how beautiful and simple the births were (and exemplify "hands off" breech!) You're able to see breech babies emerge very clearly because of the unique birth tub used, and then you can watch them swim around a little before they're brought up to the surface! The little box that pops up at the beginning says this is in Belgium. I wonder if vaginal breech is common in Belgium, or only at this hospital. I'd certainly feel more comfortable choosing a vaginal breech delivery, though, if I had a great place like that to deliver! And this is proof that vaginal breech can indeed happen, under the right circumstances.
