Dr Shawn Walker, Consultant Midwife and Chief Investigator, explains the OptiBreech position on planned vaginal breech birth at home.
OptiBreech position on home breech birth — The OptiBreech Project
Image: Jacqueline Sequoia, used with permission
From Atlanta, back to Asheville …
Jessica’s baby remained persistently breech at term, and she was unable to find a provider in South Carolina to facilitate a vaginal breech birth. When she attempted to decline a CS and negotiate a vaginal birth, she was informed that if she came into the hospital in labour, she would be given general anaesthesia and her CS would be ‘a lot rougher.’ (Folks, the ACOG published something just for you: Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy.)
This was Jessica’s first baby, in a frank breech position (extended legs), with no additional complexities. Her sister, Family Practice Doctor Jacqueline Sequoia MD, heard about Dr David Hayes and Harvest Moon Women’s Health because they were hosting my physiological breech birth training. Jacqueline includes obstetrics as part of her practice and booked to attend the workshop with some colleagues. Jessica and her husband Brian met with Dr Hayes to consider their options, and once Jessica made her decision, found a rental apartment in Asheville on Craigslist.
Let’s contemplate that for a moment. In order to have support for a physiological birth, rather than the threat of a coerced CS, women are having to relocate to another state and rent temporary accommodation, because the baby is presenting breech.
When Dr Hayes and I arrived at Jessica and Brian’s apartment, Jessica’s labour appeared to be progressing well. As people entered her space, Jessica gradually moved into the tiny bathroom at the back of the apartment, reminding me of Tricia Anderson’s metaphor of cats in labour. I turned off the light. This labour had a journey, as all labours have. Throughout her journey, Jessica was surrounded by people who love her. At the end of it, Jessica beautifully and instinctively birthed her little girl, Leliana, who weighed 7lbs 8oz.
This video contains graphic images of a vaginal breech birth.
Being attuned to the general lack of training in physiological breech birth among health professionals, and the consequences for women and babies, Jessica and Brian were keen to share this video of Leliana’s birth to help others learn. If you would like to read more about the minimally invasive manoeuvres used at the end of this birth, you can read our blog on Shoulder Press and Gluteal Lift.
Thank you, Jessica, Brian, Leliana, Dr Sequoia and Dr Hayes for sharing this video. The link to this blog post can be shared, but the video cannot be downloaded or reproduced without permission.
Shawn
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:
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/
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 Plested. Plested M, Walker S (2014) Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9):13-16 – (Archived at City Research Online)
See also the Mama Sherpas film
Like many, I’ve been dismayed by the on-line report of the RCM’s recent legal birth conference.
And I’ve been so thankful for the very clear-headed response of Birthrights.
As a midwife I regularly work with women who decide that continuous monitoring (CTG) is not the ‘right’ choice for them, despite our guidelines and recommendations that it is advisable for breech-presenting babies in labour. Of course I have the skills and competency to care for them without it, and of course I would strongly recommend they reconsider if the clinical situation were unclear without it. I felt completely deflated that a leading barrister was quoted as saying something which suggested that if I offer women the choice to do what they, rather than the professionals, feel is ‘right,’ I could be putting my registration at risk.
In offering women real choices and standing by them when they make unpopular ones, I might now be accused of promoting an ‘ideology of normality.’ Did those words really come out of the mouth of someone who sits on the NMC panel, at an RCM conference? Someone wake me up.
How could anyone who talks to student midwives today get the idea that they are only exposed to normality? While universities are doing their best to ensure they get some exposure, the students I meet across the UK are usually gagging to see more ‘normal’ births. If they are graduating with no understanding of how to read a CTG, it is definitely not because they haven’t seen them used. It is likely because their mentors are overstretched and have not had the time to mentor them fully during placements. If they cannot cope with a PPH, it is probably because they have been sent running after the ever-increasing paperwork while the PPH’s are happening, rather than being facilitated to gain experience and understanding in the moment.
I originally trained in the US, mostly in out-of-hospital settings, freestanding midwifery led units and home births. Exclusively ‘normal’ settings where almost all women chose physiological third stages. My experience of managing the not infrequent PPH’s in these environments, and having the time to debrief, reflect and consolidate those skills with continuity from my mentors over time, gave me great confidence in my own midwifery fundamentals. My experience of managing shoulder dystocias without an emergency buzzer arm’s reach away did the same.
To speak of an ideology of normality is almost sinister next to the claims that the NHS is not obligated to provide a home birth service, and that women should be told they may not have this choice. The Birthplace in England study demonstrated clearly that home births for low-risk women are significantly more cost effective than births in a consultant unit, for all women they significantly decrease levels of intervention (improving outcomes for women), and for women who have previously had a baby the outcomes for baby are just as good as in hospital.
So why is it that home birth services across England are frequently unreliable or unavailable to women, when at the same time non-evidenced-based, expensive uses of technology or other interventions are being used? For example, routine third trimester scans. They do not improve outcomes, and they increase unnecessary interventions (more cost). Yet they are still being used in some Trusts, requiring resources to schedule, administer, interpret and counsel. There are many other examples, reflecting a pervasive ideology and resource allocation agenda very divergent from what most midwives understand as ‘normality.’
So don’t be surprised if midwives, frustrated by unfair and non-evidence-based resource allocations and increasing cut-backs, start doing weird things like attending home births on days off because they cannot bear to keep letting women down. A friend of mine is fond of quoting Ina May Gaskin in times like this: “People are often punished for doing the right thing.”
Reminder: This is my personal view, and not that of the Trust that I work for (which incidentally is not one of the many Trusts which currently offer routine third trimester scans).
Update: 19/7/13 Turns out the RCM doesn’t endorse the comments made by the speakers they invited to their Legal Birth Conference who were quoted without challenge in the only report published about the conference on the RCM website. Somewhat confusing, but Cathy Warwick clarifies. Good to have the salient points clarified, but when the home birth service is unreliable about 50% of time (as reported in an MSLC meeting) in your local area (not my workplace), it’s hard to share the view that resource shortages which jeopardise the HB service are an ‘extreme situation’ with which women should have patience.
Further clarification: I still love the RCM and I’m still a member, still hanging in there, hoping for better for midwives, midwifery and women.