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 The Lancet, 356: 9239-1375) which is now very outdated being 17 years old, standardly included only planned breech births, so the results cannot be applied to the first scenario.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