Category Archives: Decision-making

Keep an eye on Sydney

Warrnambool Dreaming Weaving Panel, Lightning Ridge

Warrnambool Dreaming Weaving Panel, Lightning Ridge, Boolarng Nangamai Aboriginal Art and Culture Studio — from a previous breech-related trip to Australia

On Sunday, I am heading off to New Zealand (Christchurch & Auckland), where doctors and midwives are keen to learn more about physiological breech birth. From there it’s on to Sydney for the Normal Birth Conference 2016, where I’m excited to be giving an oral presentation about my research into how professionals develop skills to support breech birth. This is my first Normal Birth Conference, and I can’t wait to soak up the influence of so many birth researchers, including the team from Sydney currently publishing some groundbreaking papers about breech (more below). You can follow the conference on Twitter at #NormalBirth16.

I am often asked by students with a budding interest in breech birth and a requirement to write a dissertation, if I can recommend any good/important breech research papers. Why, yes, I can.

  1. The easy and Kuhnian answer to this question is: As it happens, I’ve published a good handful of peer-reviewed research and professional publications concerning breech presentation and breech birth! History may or may not deem them to be important, but if you want to know what I think is important, the reference lists will reveal all.
  2. Read the Term Breech Trial. Read all of it, including all of the follow-up studies written by people who weren’t named Hannah. Critique the research and form your own opinions about if/how it is relevant to contemporary practice. Until you have completed this task, resist the urge to claim publicly that the TBT has been ‘disproven’ or ‘debunked.’ It hasn’t. It is still a powerful force, and in fact contains many relevant lessons. Finally, read the critiques of the TBT.
  3. Now do the same for PREMODA, and if you are reading this in a few months’ time, the Frankfurt studies. At this point it will start to become interesting if you compare the reference lists of the different ‘camps’ of breech thought.
  4. When I was starting my PhD, I did a PubMed search on ‘breech presentation,’ which returned over 4000 results. I read all of the abstracts related to management of breech presentation, and all of the articles where the abstract looked interesting/relevant. It took me about 6 months. My PhD supervisors suggested this strategy might be ‘inefficient.’ Fair point. However, it’s one of the best things I ever did, as I feel confident that I have a broad understanding of research related to breech. However, I’ve muted this suggestion, as it may not fit the time constraints of the pre-registration students. It’s just to say — there is no shortcut if you want to thoroughly understand the research base in your area of practice.
  5. Finally, keep an eye on the group in Sydney who are currently publishing some very important papers. Mixing qualitative and quantitative methods, and focusing on the experiences of women and health care professionals, this team is producing research which complements the observational studies which have predominated in the past 15 years. Although each piece of research contains its own question, underlying them all, the wider questions are lurking: How did we get in such a muddle about breech? And how can we get out of it?
Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Remembering the last visit! Westmead Consultant Midwife Michelle Underwood, Obstetrician Anke Reitter, (me) Shawn Walker, and Lactation Consultant/Conference Organiser Barbara Glare

I will link a few of the Sydney papers below. Looking forward to seeing several members of this team at #NormalBirth16.

Catling, C., Petrovska, K., Watts, N., Bisits, A., Homer, C.S.E., 2015. Barriers and facilitators for vaginal breech births in Australia: Clinician’s experiences. Women Birth 29, 138–143. doi:10.1016/j.wombi.2015.09.004 — A qualitative study of interviews with 9 breech-experienced professionals (midwives and obstetricians) exploring what helped and hindered their ability to provide women with the option of a vaginal breech birth.

Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2016. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery 34, 111–116. doi:10.1016/j.midw.2015.12.008 — Additional analysis from the qualitative study above, exploring how these professionals provide care during the decision-making phase, when women are choosing mode of childbirth for a breech-presenting baby.

Homer, C.S.E., Watts, N.P., Petrovska, K., Sjostedt, C.M., Bisits, A., 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 1–8. doi:10.1186/s12884-015-0521-4 — A large qualitative study exploring women’s experiences and what women want when planning mode of breech childbirth. Open access too.

Petrovska, K., Watts, N.P., Catling, C., Bisits, A., Homer, C.S.E., 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth. doi:10.1111/birt.12249 — An international survey exploring the support women received when planning a breech birth. The researchers found that women were generally happy with their decision to plan a breech birth and would do it again in another pregnancy. However, lack of support from their primary care providers often made this difficult to achieve.

Petrovska, K., Watts, N., Sheehan, A., Bisits, A., Homer, C., 2016. How do social discourses of risk impact on women’s choices for vaginal breech birth? A qualitative study of women’s experiences. Health. Risk Soc. 1–19. doi:10.1080/13698575.2016.1256378

Petrovska, K., Watts, N.P., Catling, C., Bisits, A., Homer, C.S., 2016. “Stress, anger, fear and injustice”: An international qualitative survey of women’s experiences planning a vaginal breech birth. Midwifery 0, 464–469. doi:10.1016/j.midw.2016.11.005

Petrovska, K., Sheehan, A., Homer, C.S.E., 2016. The fact and the fiction: A prospective study of internet forum discussions on vaginal breech birth. Women and Birth. doi:10.1016/j.wombi.2016.09.012

Watts, N.P., Petrovska, K., Bisits, A., Catling, C., Homer, C.S.E., 2016. This baby is not for turning: Women’s experiences of attempted external cephalic version. BMC Pregnancy Childbirth 16, 248. doi:10.1186/s12884-016-1038-1 — Oh, thank goodness for this. The rhetoric around external cephalic version (ECV) is so strong, it almost feels a sacrilege to question it. Despite the Cochrane Review stating clearly that the evidence does not indicate that ECV improves neonatal outcomes, women are constantly told that ECV is ‘best for babies.’ Which says a lot about how reluctant to engage with the option of vaginal breech birth their providers are. This study of women’s experiences is a welcome balance to the dominant view that vaginal breech birth is only something to be considered after ECV has failed. ECV is a good option for many women, and a safe procedure in experienced hands. But it is not for everyone.

Andrew Bisits and Anke Reitter demonstrate breech skills

Andrew Bisits and Anke Reitter demonstrate breech skills

Borbolla Foster, A., Bagust, A., Bisits, A., Holland, M., Welsh, A., 2014. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Aust. N. Z. J. Obstet. Gynaecol. 54, 333–9. doi:10.1111/ajo.12208 — Technically from another team, with one cross-over member, inspirational obstetrician Andrew Bisits. This observational study helps to shed light on the clinical context surrounding these researchers. Although the article makes no mention of use of upright positioning for labour and birth, Dr Bisits is well-known for his use of a birthing stool for breech birth. You can read more about this in a previous blog, Bottoms Down Under.

Andrew Bisits performing a gentle ECV

I may have missed something, or a new study may have been published while I am writing this. (I have updated the post with some recent editions.) Best to keep a look out yourself.

Shawn

RCOG consultation on new breech guideline

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

The Royal College of Obstetricians and Gynaecologists is consulting the public on the proposed new breech guideline, until 2 May, which is Monday. Read the guideline: Here. They accept one peer review per organisation, so I will collate any comments sent to me personally or posted here on Monday afternoon, and submit them for Breech Birth Network. – Shawn

Jean-Christophe Lafaille and the HBA3C

Image: http://kylekeeton.com/product/outdoor-mountain-climbing-rock-climbing-protector-mountain-climbing-supplies-downhill-atc-falling-apparatus-free-shipping/

Image: http://kylekeeton.com/

This story about a woman’s home birth after 3 caesarean sections (HBA3C) caused a bit of a Twitter storm earlier this year. OB Prof Jim Thornton has written about his involvement here – his post and the comments below it will give you a sense of what the outrage was all about. What they won’t tell you is that a significant number of maternity service users and professional advocates active in the #matexp campaign called for an end to the storm, just as they are calling for an end to disrepectful care and divided professional camps. Their work is very worthy of your attention.

What interests and concerns me is that criticism and debate around this woman’s story seems to centre on:

  1. the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
  2. the woman’s memory that the midwife “told me I COULD have a natural birth no matter how many sections I’d had!” – and the near universal interpretation that this permission (for lack of a better word) equates to reassuring her that it was somehow the safest or the best option.
Image: http://www.unet.me/free-wallpaper/Fancy-Mountain-Climbing-1920x1408_123814

Image: http://www.unet.me/

Conspicuously absent is discussion about the woman’s description of care leading to her first 3 caesarean sections .. “As I was naive I thought I had to do what they said” .. “I was determined to have my VBAC. Until the doctor told me I was going to kill myself and my baby. So a scheduled CS was made for 38+4.” In my experience of working with women requesting support for what some might call extreme birth choices, disrespectful, coercive and often non-evidence based experiences of maternity care usually precede such apparently extreme decisions. Moderate risk-taking behaviour by a woman keen to collaborate with her care providers has been over-ruled by someone who feels they know best.

Strictly speaking, her midwives were correct: a woman CAN have a natural birth no matter how many sections she has had .. or she can try. This descriptive statement says nothing about the risk/benefit balance of such a choice, which her caregivers would certainly have discussed in detail. Women are supported to choose the mode of birth which is best for them, or they aren’t. Women are supported to choose the location of their birth, or they aren’t. ‘Risking out’ is an entirely different model of decision-making. And supporting women to exercise their own power and autonomy in low- to moderate-risk situations will potentially create fewer high-risk situations further compromised by lack of trust and respect between women and caregivers.

I would like to see more professional discussion around how we counsel women making very complex birth choices. This conversation is often difficult for health professionals because it requires an admission of vulnerability. The nature of complexity means several things could be going on at once, some of which may be new and unfamiliar and thus require more time and consideration for an appropriate response. But the nature of birth is that a crisis can emerge very quickly, and that time may not available. Experience helps. But who has a hefty bulk of experience supporting VBA3Cs?   Experience of complications is particularly valuable in such work – but how many midwives who have actually experienced a uterine rupture at home are still practising? Professionals in these situations are always out on a limb.

Does this mean health professionals should never support women making choices which increase the complexity of caring for them in labour? What should professionals’ attitudes be to such choices? One tweeter opined that the NHS should not support VBAC’s at home, because brain damaged babies cost the NHS a fortune and, “There is a limit to what you can do with other people’s money.” What exactly did the woman in question do with ‘other people’s money,’ except use the minimum required for such a birth? Should a woman be forced to have surgery because otherwise her baby might cost the health system too much? Is this really a route we want to go down as a society?

All of the outrage about women making apparently ‘risky’ birth choices contrasts with societal reactions when men make make similarly risky lifestyle choices. Stories about mountain climbers always send a chill up my spine, and one that particularly affected me was the disappearance of Jean-Christophe Lafaille during his ill-fated winter climb up Makalu in 2006. I casually stumbled upon an article in some large-circulation magazine, containing a haunting photo of his wife and 4-year-old son. I was struck by the look of loss and longing in their eyes, probably because in 2006 I had two sons of my own of a similar age. I often wonder how his wife and son are doing now.

Image: http://www.free-picture.net/sports/winter-sports/mountain-climbing.jpg.html

Image: http://www.free-picture.net/

While mountain climbers are not immune to criticism from their own community as well as those outside it, they are also glorified and funded by large companies. They usually climb with teams of people, so it is not just their own lives they are responsible for (although in the case of J-C L it was). The captivating stories of their exploits are used to promote merchandise. Even people who would never dream of scaling Makalu find their tales inspiring. The makers of the film Everest, due to be released this week, are banking on it.

Perhaps Jean-Christophe Lafaille can help shed some light on the essential humanness of risk-taking and some women’s deep desire for contact with their most basic – and essential – self:

“I find it fascinating that our planet still has areas where no modern technology can save you, where you are reduced to your most basic – and essential – self. This natural space creates demanding situations that can lead to suffering and death, but also generate a wild interior richness. Ultimately, there is no way of reconciling these contradictions. All I can do it try to live within their margins, in the narrow boundary between joy and horror. Everything on this earth is a balancing act.” (reference)

While maternity services are about safety, they should never be about enforcing some presumed collective version of what is safe onto everyone, suppressing in the process the inherently creative and often risk-taking human spirit, as well as the potential discovery of benefits in these non-mainstream choices. Nations have mountain rescue services because people will continue to climb mountains. And women will continue to want to birth their babies, sometimes in extreme circumstances. I am comfortable with my role ‘on the ground,’ so to speak, providing the standardised care which institutional systems offer and most women are happy with. I am also comfortable supporting women who metaphorically want to scale a mountain, and I will continue trying to find what sort of equipment, sustenance, maps and guidance will help them be as safe as possible while being boundary-testing humans in all their glory. I hope that maternity services can find a way through which enables more women to ‘be themselves’ in birth, as safely as possible, with an open acceptance by women and health professionals that in some instances, this may in fact come with some greater risk. I hope that maternity services can provide care which meets women’s spiritual as well as physical needs, and that judgements and coercion can recede into the past. Every woman who gives birth – however she does it – is a hero.

Shawn

(Originally written on 12 April 2015. Publication postponed due to professional blizzards.)

Related resources –

You may be interested in this article, co-written with Mariamni PlestedPlested M, Walker S (2014) Building confident ways of working around higher risk birth choicesEssentially MIDIRS 5(9):13-16 – (Archived at City Research Online)

See also the Mama Sherpas film

A Tale of Two Breech Film Premiers

On the evening of Tuesday, 30th of June, 2015, British breech aficionados were spoilt for choice. There were two important premiers of breech-related films, held in two different cities.

I was privileged to attend the Newcastle premier of doctor Rebecca Say’s Breech, the product of an NIHR-funded research project. Audience members were treated to the film, intended to be an educational tool to help women with decision-making when baby presents breech, followed by a discussion about the film, its potential impact and future plans.

IMG_6592

You can view the animation HERE, and the link can be shared freely with women and health professionals: http://research.ncl.ac.uk/breech-decisions/animation.html

The film is embedded as part of a website containing further information for women, incorporating research from many sources. Say’s research indicated women access information on-line well before meeting with health professionals, and finding balanced, useful and unbiased information was difficult. Maintaining the Breech Decisions website will depend on further funding, but it is a useful, up-to-date tool at the moment. You may also be interested in Say’s qualitative research about women’s experiences of ECV (2013).

IMG_6600On the same evening, a group in London assembled to view the Heads Up film with Dr Stuart Fischbein, visiting from Los Angeles. The film is a passionate plea to #reteachbreech – and you can find out more about this project on this Twitter hashtag, or Dr Stu’s Blog.

Fischbein has also recently published his statistics – “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births.

– Shawn