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

Overdue Breech

I was reminded via twitter this week of my clumsy attempt at comedy when speaking at the fabulous CCSU MidSoc conference earlier this year: “I am, like many others, a little frustrated at how long we have been waiting for the RCOG to revise and update its guidelines; they are so overdue if they were a baby they would have been born by emergency caesarean section by now” (don’t worry I’m keeping the day job…).
The current RCOG breech guidelines were published in 2006, a whole 10 years ago. Only 1 other green top guideline is older (Tubal Pregnancy, 2004) so why is the breech guideline taking so long when there have been several good pieces of research and mounting evidence that a change of guidance is required?
We all know that change in healthcare can be really slow; like a massive ship trying to change course with a reluctant captain who rather likes the view as it is. But there are rather telling examples where change has been rapid. When the Term Breech Trial (Hannah et al, 2000) published their controversial results of their breech research in 2000 the number of vaginal breech births declined dramatically across the world. In the Netherlands, caesarean section for breech rose from 50% to 80% within 2 months of the publication of the research (Reitberg et al, 2005) and it has been said that no other research has impacted an area of clinical practice in such a short period of time.
It appears that the good captain had already plotted the course and was just waiting for the green light to turn hard right, full steam ahead. My obstetric colleague whispered that it was a relief that they would not be called for the odd ‘difficult’ vaginal breech in the middle of the night again; much easier the planned caesarean at 10am.
The move to surgical delivery for all breech babies at the turn of this century could not be more neatly presented as an example medicalisation of childbirth. Breech was redefined in a moment as the abnormal, dangerous and in need of obstetric intervention and rescue. And women’s birth choices were effectively removed.
The ship needs steering back on course; vaginal breech is a safe option for some women according to the current evidence, but I fear there is some reluctance in some quarters. Medicine, who advocates the authority of research to guide clinical practice, appears distracted and unconvinced when presented with current research that supports vaginal breech birth as an option. Local breech clinical guidelines reviewed and updated with the most up to date evidence, are not signed off as they don’t align with the 10year old breech RCOG guidelines. And I continue to hear that women are still being told they are ‘not allowed’ a vaginal breech birth or that there ‘aren’t staff with the skills’ to support their choices.

Unacceptable.
In this age of medical dominance the RCOG is a powerful and influential body which can make a difference. The draft RCOG breech guidelines I was able to review and comment on earlier this year were a huge improvement and will be a game changer for women and advocates for women’s birth choice (surely this is everyone??).
So I look forward in anticipation to these overdue breech guidelines. I know there are stirrings and that labour is imminent; not normally one to interfere, in this case I would offer these breech guidelines a stretch and sweep to move it along a little swifter – just give me a call.

#breechgeek