Unexpected breech = No drama!

I was contacted recently by some midwives who had attended one of the breech workshops I have facilitated this year. They wanted to share their story of an unexpected breech birth and how thrilled they had been to be able to support the woman; no transfer, no drama, just a beautiful birth.  They described the baby needing a little nudge to help its head be born drawing from the toolkit of skills and practices that we shared and practiced in the workshop, and how the baby cried immediately, safe and in great condition.

It was an utter delight to hear their joy and confidence in themselves and in the breech birth process.  This is raw birth, it just happens to be breech.

This story was very different from a birth I was involved with many years ago, one of the first few breech births I attended and the start of my breech journey. I was working in a midwifery led unit, it was 4 am and a colleague and I had an unexpected breech baby needing a bit of help to be born. I had no toolkit to draw from and I had no real understanding of why baby had stopped coming and how to resolve it. My only training for breech has been as treating it always as an obstetric emergency with a single manoeuvre for assisting the baby’s head should it be needed.  It didn’t work. And I had nothing else.  So, I drew from what I knew from all the births I had attended over the years and figured it out and the baby was born and was fortunately fine. I was, at first, just very relieved, but this turned to confusion and then frustration.

Why did I not know more about breech births? Why did this baby need a hand and how could I have prevented it? This was the first breech where the baby had required my help – the other few breech births I supported had been very straightforward – so why wasn’t I taught breech as a normal process so I could understand the difference between the ‘normal’ breech and the ‘dystocia’ breech. There was a mighty gap.

So. I listened A LOT to many wise women, midwives and birthing mothers, older obstetricians and midwives who delivered breech routinely rather than defaulted to caesarean section back in the day, birth workers who had practiced abroad in countries where breech is just another birth. And I read A LOT. And I did a PhD research study into breech. And I gathered a whole toolkit for normal breech birth and for when the baby needs a hand.  Nothing in the toolkit is complex; its just pulling together our extensive birthing knowledge, a smidge of research (there is limited quality research out there on breech), shared experiences and a good dose of common sense.  The toolkit allows us to replace FEAR of breech with RESPECT for breech.

I believe ALL midwives can and should have good breech birth skills; inevitably the unexpected breech arrives at 3am in birth centres or at home with little chance of transfer or rescue from breech ‘experts’ – so all midwives need to be able to be confident with breech birth not just a few. It doesn’t require complex and expensive courses, but a groundswell of shared learning and ripples of knowledge sharing; a shift back to belief in breech as a predominately normal birth but, like ANY birth, the identification and resolution of deviations from this norm.

There should be a clear distinction between breech as a normal birth and breech requiring help. It requires a change to the current midwifery curriculum and skills update days; breech should be taught and understood within a normal birth context, then breech dystocia should be taught within the obstetric emergency model.  There should be a clarity on how to support normal breech labours and births and identifying deviations and then providing a TOOLKIT of skills and practices from which to drawn on should help be required.

So, rather than the drama that can ensue when breech position is discovered lets skill up, share our stories and experiences and get breech confident!

 

The language of breech

I was lucky enough to be invited to speak at the RCM and Maidstone and Tunbridge wells Maternity services annual conference this week. This was a fabulous day with a variety of speakers and attendees who shared their experiences, thoughts and vision of being the change in maternity services.  Inspiring talks,  driven and positive students and midwives and service users made for a wonderful day and the homemade food at lunch was just an extra bit of delicious (thanks to Sarah and her family).

The language we use and hear is a quick barometer of current position and culture. Cathy Warwick wants to ban the phrase ‘allow’ anywhere within the spectrum of maternity services and birth; our remit is not to prevent, police or judge but to enable, inform and support.  Lots of vigorous nodding agreement on this one. But sadly the multitude of stories from women (and midwives) that includes ‘I wasn’t allowed’ persists daily so this is our current narrative and one that we need to face.

How can we change it?  It seems simple but it can be deceptively hard when  medicalisation of birth has embedded a medical language and strong powerful hierarchy enables it to persist.  But it can be done one person at a time.

‘I alone cannot change the world but can cast a stone across the waters to create many ripple’  Mother Teresa

Breech language

For many years I have refused to use the term ‘undiagnosed breech’. Breech is not a disease, it is not an abnormality, it is not something requiring a medical diagnosis. It is just different, a bit unusual and relatively uncommon. Occasionally there is an underlying problem that has caused the breech position so this, of course, has to be explored but mostly there is no issue, breech just happens. So I use the descriptors ‘unplanned breech’ or ‘unknown breech’ for when breech is discovered.

Once known, its then a question of a good thorough review. In medical terms this is called a ‘risk assessment’ but this to me is remarkably negative; I want to find all the risks relating to you then we can tell you what you may be allowed to do. Instead lets call it a safety review; I want to take you as an individual and make sure you and your baby are as safe as possible. Much more positive and much less like a test to pass or fail.

And another one to consider if we really are going to provide real birth options for women is the term ‘breech expert’.  Medicine, the legal profession, and the media, are really keen on ‘experts’. They hold extraordinary powers to persuade and command respect and awe. But they are difficult to define. Who or what determines the expert and who is able to challenge them and their opinions?  For birth if we create breech experts who are the only ones to support women with breech births this severely limits our service provision in this area. It risks disempowering midwives and women who will be the ones at 3am at a birth centre with an unplanned breech in advanced labour. It risks breech becoming more detached from the sphere of normal birth, more medicalised and a significant disruption to women on their birth journeys.  If only breech ‘experts’ can teach breech we will end up with the medical type approach with expensive elite courses and competencies to achieve before we are ‘allowed’ to support a breech birth?

Instead can we take a step back and consider breech birth as just a birth that requires respect,  knowledge of A&P, recognising the reassuring normal signs and signs of when the baby or mum are asking for help (as with all births).  All midwives [and obstetricians] need to be breech confident. They need to be able to recognise when a problem occurs and what to do, just like for cephalic birth. So lets see and teach breech in 2 ways; as a normal physiological event, which the majority (70% for upright breech birth according to study by Bogner et al, 2015 ) are. And teach breech dystocia as part of the maternity emergency training alongside shoulder dystocia, when and how to help the baby.

Language is vital for shaping a culture, and each of us plays a part in this.  Use a different language and start the ripples.  Together we will make waves, and soon the tide will turn for more positive, collaborative and confident breech narrative and practice.

Dr Jen

I am currently travelling around the country providing affordable and accessible workshops to share breech skills, stories and knowledge.                #bebreechconfident       #notanexpert     #breechgeek

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The Honest Breech Broker

During the breech geek tour bringing breech birth skills workshops around the country I have heard many similar stories from student and midwives about their experiences of breech. However, there are a few stories that I will hear at EVERY session; the names may change but the stories are the same:

First, the story of the multigravida lady, previous normal births, who arrives in advanced labour with an unknown breech who is summarily whisked off for a category 1 caesarean section – the team at breakneck speed adrenaline pumping.

Second, often the same scenario as above but with the following addition: a lady who is found to be carrying a breech baby is ‘counselled’ that she can have a vaginal breech if she wants but it’s very high risk, the baby may die and a caesarean section is much safer. She always ‘choses’ to have a caesarean section – I mean who wouldn’t – and feels very grateful for being saved from the probable death of her unborn should her failure of  baby / body / nature been allowed to occur.

Neither should happen.  Neither is based on current evidence. Both violate the rights of women.

As a health professional we have a duty to provide evidence based care, to ensure women are fully informed of their choices and that their decisions are supported. Above scenarios show that care is frequently not evidenced based. There are only 2 small studies specifically on unplanned breech and their outcomes (Usta et al. 2001. Undiagnosed breech: impact on mode of delivery and neonatal outcome. Acta Obsterica t Gynaecologica. 82:841-844 & Bako et al, 2000. Undiagnosed breech in Zaria, Nigeria. Journal of Obstetrics and Gynaecology. 20:2:148-150). Limited as these studies are they suggest that for the baby, there is no difference to their wellbeing regardless of if they were born vaginally or by caesarean. The larger studies, including the very poor quality Term Breech Trial (Hannah et al, 2000. Planned caesarean verse planned vaginal birth for breech presentation at term: a randomised multicentered trail. The Lancet, 356: 9239-1375) which is now very outdated being 17 years old, standardly included only planned breech births, so the results cannot be applied to the first scenario.

If there isn’t research evidence to support this then is there shared clinical knowledge we can draw from? Well, my experience of working in birth centres where we had regular unplanned breech births, the scenario was very different.  A low risk woman in advanced labour with no clinical concerns would progress to a vaginal birth (if there was time women were given the option of transferring to a nearby obstetric unit). A woman who arrived with signs of poor progress, an unhappy baby or other clinical concerns we would advise transfer to the main unit and usually have time to get there.  Speaking to other midwives with breech birth experiences, and by the way there are a lot out there despite the repetitive cries all the breech skills are lost, this bears out. Shared experiences suggest that unplanned term breech labours and births on the whole do well; they are usually spontaneous, progressive, they have had no interventions and the outcomes are good. Unplanned breech labours that are not going well bail out for a caesarean section; but this is a logical safe approach.  So if the research is lacking, the clinical evidence is that a an unplanned term breech labour going well is fine to continue on to a vaginal birth then why are we taking women for caesarean sections?

Being honest, this is about lack of confidence, fear and the result of medicalisation of birth. Obstetricians are confident with surgical birth, even cat 1 LSCS, as they are a common occurrence. They are not confident with vaginal breech birth, skills of which are far more attuned to the normal birth skills of the midwife; to watch, to wait, to observe, to support women’s choice in their birth position (OMG not all 4’s!!) and to identify when intervention is required.  The research doesn’t exist (yet) but it would be fascinating to compare outcomes (mum and baby) from unplanned breech in birth centres to unplanned breech in obstetric led labour wards (any takers?)

We also, naturally, fear what we don’t know. The medicalisation of breech has meant we see few vaginal breeches and fear the unknown. Media-style hyped horror stories are mutely shared in staff rooms about the most horrific breech birth a colleague of a colleague was at.  Unhelpful but these stories shape maternity unit culture and influence how staff respond.

Secondly the informed choice debate continues. Following the Montgomery case, and many would argue it has always been required, there are explicit requirements on the information provided to women on which to make their decisions. This means information must include evidence; from research and shared clinical knowledge, it should be factual and applied to the individual’s circumstances and situation and where information is given as an opinion it needs to be clear that it is opinion not presented as fact. If an obstetrician has the opinion that vaginal breech birth is not safe then it needs to be presented as opinion. There is some research evidence to support that opinion but it would be incorrect and wrong to state this as fact as there is substantial research that suggests when appropriate risk assessment is undertaken vaginal breech birth is a safe option. We also need the RCOG to pull their finger out and publish their revised Green Top guidelines on breech, the one on line today is over 10years out of date – significant FTP here!

So, ultimately we need more honesty when counselling women. We need to say when information is provided as an opinion or that the research is a bit ropey. We need to say when we feel out of our depths and fearful, but we also need to do something about this through education and training. It’s a cop out to just say ‘I have no experience with vaginal breech so I won’t do them’; we have a professional obligation to stay up to date, appropriately trained and able to provide care within the scope of our practice and vaginal breech is certainly included.

For breech to again become a real option for women we need to ensure the narrative is honest; we need to split the opinion from what limited evidence and research we have and help women make decisions that are right for them not right for the system or doubtful health professional.  We need to gather the current knowledge we have, which I believe there is a lot of despite the constant cries of ‘lost’ breech skills, and share them widely and quickly.  We need to reclaim breech as a normal birth, well within the realms of midwifery practice where we are fully trained to recognise when mum or baby needs a hand and call for help.

And finally we need to stop fear and fear based-narratives entering the room; the damage we are currently doing to women, to babies, to birth workers and maternity services is huge, but as yet not collectively measured. For each of these stories there is a woman, a family and often a health professional directly affected.  Health professionals need to be honest brokers about birth to build trusting relationships, meet their professional and legal requirements and ensure safe and quality experiences for all involved.

Dr Jen

#breechgeek

I am currently touring the country doing breech skills workshops, sharing the breech love. If you are interested in hosting a workshop contact me for more information: breechgeek@gmail.com