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

workshop

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

Breech: Ordering off the menu

36164523 - new born baby feet. hand of the mother holding the sleeping baby boy little foot up.

I used to not be very adventurous with food. I wasn’t a fussy eater as such I just hadn’t been exposed to different types of food when I was young so I was quite cautious. I was gently introduced to the world of flavour through a korma curry when I was 20, and now elbow people out the way to the hot and spicy counter and love trying new things.  I have even had a go at ordering off the menu, either driven my taste buds or that nothing on the menu was my thing. And mostly this has been a good experience, with me, the customer humoured and accommodated. Occasionally there is a stony ‘no’ (it’s just not possible in pre-cooked greasy burger joints) and on the very rare occasion I was in fear of being ejected from the premises for even daring to imply the menu was inadequate (a rather snotty pretentious restaurant in my view).

Is modern birth services options like a menu? Who develops the menu and how is it presented? How easy is it to order off the menu and what is that experience like?

Practically the menu is mainly the clinical guidelines that help clinical staff decide the best thing to do based on the evidence available.  My experience is that whilst some commonalities can be found, local clinical guidelines vary due the rest of the stuff that has a significant but rarely acknowledged impact on what ends up on the menu. Stuff like personal views, experiences, beliefs and ‘how we do things round here’ impact on what is in a clinical guideline.  I was once, some years ago,  in  a team who were updating breech clinical guidelines at a maternity unit when I was told to tone it down (I think I was including the option of active, upright breech birth section) or I would never get it past the obstetricians. This was despite my arguments that giving being required to give birth on your back in stirrups as per the current guidelines had no research basis at all. My text remained in (stubborn me).

I am aware that in some maternity services the users of that service, the women and their families, have no input into the development of clinical guidelines that directly affect them; the menu is off limits in terms of deciding what’s on offer.  Perhaps a chef would argue that only she/he, the expert, would know what food is best to serve. But of course we are not talking about food, we are talking about birth and who is the expert at birth (my vote is birthing women).

But what if nothing on the menu takes your fancy. Hold the beef and potato stew, I’m hankering after roasted snails cooked with pineapple and paprika today kinda thing. Well, from listening to many women’s breech birth stories, there are mixed responses but a common one is of a sad battle to get their pineappley snails/not on the menu birth choices. Some women are given the ‘no can do’ response (think greasy burger joint) and others are made to feel very alienated, ostracised and even stupid from even asking for their desired snails (think snotty restaurant). Some even leave the entire food joint and go and find a nice chef (in another maternity unit or independent midwife) who will listen, respect and facilitate their choices.

Ordering off the menu is hard work, it can be stressful and women share that it harms their relationships with care providers who won’t consider their needs. Perhaps then we need to look who and how the menu is developed. Including the people who use the service in clinical guideline development is a no-brainer, it is empowering and enabling and forms partnerships of trust and respect. Maternity Service Liaison committees do sterling work in this area. Involving service users in research and building and sharing of knowledge around birth is also common sense. What’s important to those giving birth should be the central starting point for developments and innovations. Ordering from the birth menu that you shaped is much easier than choosing off the chef’s version of culinary heaven.

And finally we need to consider if we need a different type of menu; is there a new way of doing things out there? The maternity services review certainly thinks it’s time for a change. The proposed personal budgets will certainly go some way to empowering women in their birth choice and feel more like the buffet style approach to birth. They offer you to take a plate and fork and add the tasty morsels you desire to build a meal that really tingles your taste buds; your own unique birth journey how and where you want it.

Pineappley snails are not for everyone, but nor is beef stew. Let’s change the birth menu and the mindset of choice.

#breechgeek

Giving birth to stars

After having a catch up with a lawyer friend last week I reflected on the desirability of certainty, and its antithesis, the messy reality of uncertainty.  The law, my friend tells me, provides considerable certainty, especially so when considering principles known as the ‘black letter law’. This impressive term is defined as:

‘a principle of law so notorious and entrenched that it is commonly known and rarely disputed’ (Duhaime’s law dictionary)

This is when a belief, view or understanding becomes so resolutely agreed by those who hold the power, in this case judges, it becomes indisputable ‘fact’ and ‘is no longer subject to reasonable dispute’.  Interesting stuff. It must be really helpful to have these entrenched beliefs to guide you as you confidently go through life; they are a given, an absolute, a certainty on which you can pin your colours and not worry again.

This brings me to some thoughts; how attractive certainty is, how you don’t need to worry if you are certain so it makes things a little bit easier. And how fragile certainty is, based on the collective views of others, often those in power, but passed to us as indisputable facts. And how birth can be such an uncertain time in a generally uncertain life.

In midwifery uncertainty is acknowledged and accepted as part of birth. As a midwife I learnt to be patient, to observe and prepare for any eventuality. The many nights waiting to be called for homebirths over the years was a warm reminder of how beautifully unplanned nature was. I learnt from women and their unique and individual birth journeys, spotting the common threads between them that help you to know the few occasions when women or babies needed help.

My experiences of discussing certainty and uncertainty with my obstetric colleagues has been fascinating.  A good example is induction of labour when pregnancy is considered overdue (usually around 41 weeks gestation). I chatted with a doctor a few months ago who was convinced that no women would choose to continue the burden and uncertainty of pregnancy over ‘getting on with it’ induction, with the added benefits of being guaranteed a baby in arms by dinner time the next day-ish (very ish).

But despite the ongoing debate on what really is ‘overdue’ in pregnancy terms and ongoing concerns over the risks / benefits of induction this intervention has been widely adopted, leading to nearly a quarter of all pregnancies being induced (see Rebecca Dekker’s excellent summary here). But perhaps the attraction of induction is the attraction of certainty, for many it must be good to know they are on the final run and there is certainty in being told you will likely be back home with a baby in a day or two or three or four.  It certainly helps with your Facebook status and stops those pesky enquiring phone calls from friends and family.

But what would happen if we turned this on its head and dealt with uncertainty in a different way. Uncertainty can bring stress and unhappiness but can also be the way that amazing things can happen, where we are more than we ever thought we could be.  Women who I have talked with about their breech birth experiences described periods of intense uncertainty where they didn’t know what to do, they felt stressed and often fearful, exacerbated by the fears of others.  Women described navigating this uncertainty finding their way and seeking alternatives and people who would listen and support them.  But they also described the moments where they made their decision on how and where to birth, drawing deep within themselves and from others to reach a place of self-certainty about what to do next.  These women described how they drew strength and confidence in themselves and their babies from their birth experiences, though many expressed how they wished they hadn’t needed to battle so much to have their decisions respected.

Perhaps this tells us that uncertainty allows a time for looking outside the box, ordering off the menu. It also suggests that certainty is very personal, rather than an entrenched notion or concept that is applied to (imposed on) all similar situations and populations. Developing self-certainty can be empowering as it develops from an individual’s own ideals, beliefs and situations, rather than those of others.

This doesn’t just apply to breech birth of course; women are faced with many situations within their pregnancy and beyond into motherhood where uncertainty and certainty go hand in hand.  Certainty through care pathways doesn’t always provide definitive answers or guaranteed outcomes. Uncertainty is not always a negative, but perhaps also an opportunity for liberation and freedom of choice.

‘You must have chaos in your heart to give birth to stars.’  Nietzsche

Whilst we may not desire chaos, uncertainty may provide opportunities to explore, to consider the alternatives and perhaps, even, to give birth to stars

#breechgeek

www.breechbirthing.com

e-mail: breechgeek@gmail.com

Twitter: @JenD2605

Breech Skills Workshops – low cost high value

As a commitment to reinvigorating confidence and real options for breech I am currently offering workshops for ‘expenses only’ cost. This means if you can get a group of students or qualified health professionals together, ideally between 8-15 people, then I will travel to you and facilitate a 4/5hr breech skills workshop.

Here is what’s I can offer:

  • I have been a midwife for nearly 20yrs and have worked in all types of maternity care settings and home
  • I am a qualified teacher and for over 10yrs have taught breech birth skills, with upright breech skills being the norm,  to midwives, obstetricians and students
  • I have clinical experience of supporting breech births,  both upright and other positions. Most breech births I have attended have been straightforward but a few have needed help
  • I have completed 2 research studies on breech, and finished my PhD on the experience of breech birth in 2015.
  • I learn from women and other birth workers continually; experiences and stories are strong and important part of birth skills knowledge

I believe learning should be accessible and practical and teaching clear, memorable (in a good way!) and honest.

I believe breech skills are like all birth skills; they have fundamentals in basic physiology and anatomy,  recognising when some births need help and having a toolkit of things to provide that assistance keeps mums and babies as safe as possible.

I believe breech birth does not need to be high-risk obstetric-led but is a birth that does best with teamwork, support and respect.

Sounds good?

Contact me and we can have a chat: breechgeek@gmail.com

See what other people say about the workshop here