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
I’m honored to be asked to be the guest writer this week on breech. Shawn Walker is an international inspiration to those doing breech work around the world in various settings providing tools for breech birth to be safer and more accessible.
My journey to breech started with the breech homebirth of my daughter, Nilaya, who is now 12 years old. I was a student midwife just starting to catch babies here in the U.S. and had my first two head down babies steeped in a culture of home birth where twins and breech were normal. The choice to birth my third baby breech at home was not difficult. I did not have to fight for it. I just did it. It was through this birth that I became invested in understanding and preserving this part of the craft of midwifery.
Getting experience and quality training in breech has been a challenge. I’ve had to seek out workshops and conferences from across the United States, take online international courses, and work to understand the mechanics of knowing normal vaginal breech birth. Even though I am an instructor at our local midwifery school and have developed the curriculum here for breech birth, I still have limited hands-on experience that is slowly growing through the years. As a Spinning Babies Approved Trainer, I get many referrals for breech parents and help them to navigate breech late in pregnancy through counseling, bodywork, and midwifery skills. It is amazing what skills one picks up with their hands from seeing so many families and palpating so many breech presentations. Being able to have breech immersion of any sort can help keep the knowledge and skills alive.
We are at a crossroads here in the U.S. for breech where in state after state, midwives are being limited by laws for attending breech and have not had a bar set for what breech birth competency looks like. We might have a small list of skills, but with breech complications, we know that the refined skills can make a difference in outcomes. If we have the ability to show experience, understanding, and investment in training, we might set a different course for breech, and midwives might actually set the bar for competency and have influence on other professions. I am interested in how we can provide a more thorough understanding of what Shawn Walker deems “Respecting the Mechanisms” and “Restoring the Mechanisms” of breech. In this way, I also believe that we can shift the paradigm of “No normal breech” to “Know normal breech.” The international breech community, in how it is detailing the mechanisms of breech birth, can actually be a model to those doing vertex deliveries! One of the reasons for a higher cesarean rate here in the U.S. is fear of a shoulder dystocia In understanding the mechanisms of normal and restoring these mechanisms at all levels of the pelvis could reduce interventions and improve outcomes. There is value for all births in utilizing gravity and mobility to increase diameters of the pelvis or to safely reduce fetal diameters when presented WITH complications. Respecting that the reflexes of a baby being born are also part of the mechanisms of normal birth may not be seen with a vertex baby, but we know that babies help themselves to be born.
As the international breech community discusses developing breech birth centers and (re)teaching breech, I’ve worked on how I can document my own road to competency and compiled these ideas in the format of the student paperwork for the North American Registry of Midwives (NARM). I naively thought I would just submit them for review, but the interest of a larger community has to also be there. There must be more conversations in the community over how such documentation can be useful and how to avoid potential pitfalls of its use. I have called it “Breech Competency Documentation” so that it provides a way for birth workers to document skill acquisition as well as experience. One could choose to keep the documentation on file for themselves or even to be part of a larger program.
I am sharing below three out of four documents I created that are works in progress and open for suggestions. I want to create a community conversation and am posting these publicly as birth workers in various countries have asked me for such information which I find valuable. As we gain more knowledge about breech, these skills checklists can be updated to reflect the current knowledge.
The first document, which is modeled after the NARM skills list, is a compilation of the current skills being developed in the international breech community. I acknowledge that some Qualified Breech Preceptors may practice differently, but these skills are about developing a baseline for understanding upright normal breech and upright breech complications.
The second document, which is modeled after the NARM requirements for becoming a Certified Professional Midwife (CPM), outlines experience for assisting and being a primary student under observation of a Qualified Breech Preceptor. I originally considered requiring higher numbers of birth / experiences / skills on these lists, but I then realized that it as going to be quite difficult to acquire those numbers of breech deliveries because of the overall low percentage of babies who are breech at term. I decided that we must focus on quality of skills and of each birth attended and included the ability to use retrospective births that can be debriefed and reviewed with the preceptor.
The second document, which is modeled after the NARM skills list, is a compilation of the current skills being developed in the international breech community. I broke down the skill categories starting with breech pregnancy, normal vaginal breech birth, complications at the different levels of the pelvis, and small section of postpartum care.
The third document is for the student / midwife to list retrospective births they may have had and document the process of review with a Qualified Breech Preceptor. This allows previous births to be able to be integrated and reframed within this format.
The fourth document I have started but not posted and it is pivotal in the overall conversation of Breech Competency Documentation regarding who would or would not qualify as a Qualified Breech Preceptor. Through this documentation I believe we must point to the Delphi Study and its baseline as being above 20 breech births. However, attending a certain number of births without any complication may not lead to more competence than someone who has had fewer births but had to resolve complications. As I was creating this paperwork as a student of breech birth, I questioned whether it should be a document developed in more detail between preceptors and experts.
I want to thank all of the people who helped me review the skills list for Breech Competency Documentation including Gail Tully, Diane Goslin, Shawn Walker, and Vickii Gervais. I also want to thank Rindi Cullen-Martin for helping me with formatting and making the changes. Both of us as breech mothers have an investment in continuing this work. This work has also been influenced by the international breech community including Jane Evans, Mary Cronk, Anke Reitter, Frank Louwen, Maggie Banks, Anne Frye, Betty-Anne Daviss, Mary Cooper, Peter J. O’Neill, Andrew Bisits, Stuart Fischebein, and many others.
Nicole Morales, LM CPM is a midwife with a home birth practice in San Diego, California. She is a Spinning Babies Approved Trainer, an instructor at Nizhoni Institute of Midwifery and a Certified Birthing From Within Mentor. She and other breech mothers have worked on the website breechbirthsd.com to compile information for families and providers navigating breech pregnancy and birth.
This week, the NHS Trust where I work is honouring the great work of our Maternity Services with a day-long celebration. This includes a bake-off. I have never participated in a bake-off in my life. I don’t really bake much at all. But Victoria Cochrane and I were inspired.
In addition to our wonderful colleagues, we also had celebrations of our own. To begin with, amazing Matron Victoria recently managed to secure funding to purchase mobile ultrasound scanners — for use by the same Community Group Practices which have just been shortlisted for an RCM Better Births award! These scanners in the community will make it easier for women to find out if their baby is breech without having to journey to the hospital, and help minimise the number of women who find out their baby is breech in labour. This will mean more women have the opportunity to consider an external cephalic version (ECV), and/or have a choice of mode of delivery for their breech baby.
Victoria and I have also co-authored an article in The Practising Midwife this month, where we advocate that midwives adopt a ‘plan or scan’ policy to reduce the potentially negative impact of unexpected breech in labour. By this we mean, either inform women antenatally that there is a risk (approximately 1:100-1:150) of an unexpected breech in labour, and encourage them to think about what they would do in that situation, or consider adopting a policy of third trimester presentations scans for low-risk women. We also advocate identifying a group of obstetricians and midwives willing to be called upon to attend a breech birth — a breech team. No need for a 24-hour rota; just identifying a team and involving one of them wherever possible will begin to make a difference. We could do with more research on women’s experiences of unexpected breech in labour as well.
So, the cake:
Maybe it will make it into the hospital newsletter!
Congratulations also to the Sheffield Breech Birth Service, which has also been shortlisted for an RCM Award for Excellence in Maternity Care. The team have been providing continuity and a realist option for women wishing to plan a vaginal breech birth for years, and are a model of what can be achieved when midwives and obstetricians work together to deliver a high quality, safe and respectful service.
Breech advocacy work is a long-term commitment. Things don’t change overnight. Sometimes, we just continue to keep breech on the agenda, reminding ourselves and others that breech does not equal an automatic CS. Midwives and obstetricians continue to stand up for the right of women to choose their mode of birth after balanced counselling and a realistic offer of support for all options.
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:
- the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
- 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.
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.
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.
(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