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

Click here for more info

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

 

 

Down in the Trumps

I recently read that it really does seem that David Bowie kept the world in order; proof is the rather crazy world events that have occurred this year since his very sad demise.  It has been a roller coaster year and its not quite over yet…

The certainties are a lot less certain following Brexit and Trump or perhaps the illusion of certainty is being uncovered. In my most optimistic moments (there has only been one and it was after a shandy) I think perhaps the changes afoot will bring opportunities, improvements and a fresh approach to long standing problems. But then I look to those who hold power and fear that the marginalised will become more silenced and I reach for the chocolate cake and worry.

What will all this mean for maternity care?  The impact of these world events ripple all over and impact on relationships, behaviours, tolerances and social norms. The more inclusive, socially aware and diverse societies tend to develop quicker and stronger than those which are narrow minded, punitive and reduce the rights of those who are not represented in positions of power.  Are we growing as a nation (or world) or have we just shut the doors and built the walls that will restrict and limit our growth and development?

Will maternity services become more restricted by lack of funds and staffing pressure to meet the needs of pregnant women and will there be less tolerance for those who want something different from the often limited pathways of care offered?  In my work life journey I have heard some terrible birth stories of women feeling isolated, ridiculed and made to feel unsafe for wanting to make their own decisions at a time where they are most vulnerable; heavily pregnant or in labour.  I have also heard warming stories of those same women being supported, guided and respected for making their own choices.  We need less of the first and the norm of the second.

My worry over events of this year is that the ripples will mean women will be heard less, there will be less diversity and growth and the options will reduce.  But we must not retreat to cake, we must put the fork down and speak out!

There are lovely things happening as well that balances my cake wobbles. It is wonderful that the fabulous Neighbourhood Midwives have signed their first NHS contract with Waltham Forest CCG, a great collective working that will surely strengthen maternity services as well as being a great option for women in that pocket of the world.  Congratulations to them!

A few weeks ago I ran a breech skills workshop for student midwives who were inspirational in their commitment and enthusiasm to learn and shape their own midwifery journey and that of the future maternity services.  So warmed by the next generation of birth workers I committed then and there to do as many breech skills workshops as possible, for cost, to do my bit for increasing birth diversity, ensuring options remain for those who tread a different path and support staff who need just confidence in their own breech knowledge and skills. So if you fancy a fab breech skills workshop in your area give me a shout – I may even bring my chocolate cake!

breechgeek@gmail.com

#breechgeek

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