Monday, March 15, 2010

controversy about breech births

Breech Birth Woman-Wise, published in 1998 by NZ midwife Maggie Banks, is an excellent and very useful resource for midwives and for women considering the need to give birth to a breech baby.

 Tomorrow the first year medical students at Monash University will be exposed to some of the contorversy that exists around breech births. The class is Sociology. Most of these students are bright young school leavers whose almost perfect scores in their VCE exams have allowed them to take their first step into the privileged world of medicine.

The course seeks to expose the students to the views of a range of participants, including women who have had a breech baby, midwives in private practice, private obstetricians, and lay birth support people. I have participated in this class for several years now. It would be easy in this debate to present a black and white, 'medical/surgical' versus 'midwifery/holistic' scenario, but that would not be truthful. I hope to demonstrate informed decision making that occurs within a professional relationship between mother and her known midwife.

The aim of the class, and subsequent tutorial discussion, is to ensure that the students understand that people have divergent views on professional bodies of knowledge that inform decision making in maternity care, and develop some understanding of the roles of individuals within maternity care.

Four instances of breech birth come to mind. By telling the stories of these mothers and their babies, I hope to share my knowledge in a way that will be useful to others.

We will call the four women A, B, C, and D.

They were all well women at Term, and the reason they are appearing in this account is that their babies were all presenting bottom-first, breech. This presentation occurs naturally in approximately 3-5% of babies at Term.

Mother A was pregnant with her first baby. At 37 weeks' gestation, after abdominal palpation and auscultation (listening to baby's heart sounds) the midwife was confident that A's baby was breech. After discussion A decided to request external cephalic version (ECV). However the obstetrician who performs ECVs disagreed with this plan, as ultrasound showed that the level of amniotic fluid aroung A's baby was less than normal. The obstetrician recommended elective caesarean surgery. A's choice was breech vaginal birth, against medical advice, or elective caesarean. She chose caesarean.

Mother B, pregnant with her second baby, was planning homebirth with an independent midwife. At 38 weeks' gestation, B told her midwife that she thought her baby was presenting as breech, as she was aware of a hard round lump (her baby's head) just under her ribs. B went to the hospital and requested ECV. Her request was denied, and she was told she would be scheduled for caesarean surgery. B went home and arranged acupuncture and moxibustion from her traditional Chinese medicine practitioner, without the desired effect. After several subsequent conversations with hospital staff, B was able to arrange a consultation with the obstetrician. B convinced the obstetrician to attempt ECV, having informed the doctor that she intended to proceed with vaginal birth whether the baby had turned or not. The ECV was successful, and B gave birth at home the next day.

Mother C, pregnant with her second baby, was booked to give birth at a suburban private hospital. C's doctor was happy with her condition when he checked her at 38 weeks. At 39 weeks' gestation C's labourb began spontaneously. C arrived at hospital in strong labour, and shortly thereafter her membranes ruptured. The presence of unmixed meconium in the amniotic fluid suggested undiagnosed breech, and with the next contraction the baby's feet were visible. The hospital midwives called the doctor urgently, and he said he was on his way. The midwives prepared C for 'delivery' - lying on her back on the bed, with her legs in stirrups. About 10 minutes after the waters had broken, the baby's body was visible up to the shoulders. There was a small bright bleed, and the baby became pale. The umbilical cord stopped pulsing. The doctor arrived only a few minutes later and delivered the baby's head, and proceeded with resuscitation of the baby - artificially stimulating heart beats and breating. The baby was taken to special care nursery, and although he survived, he was later diagnosed with cerebral palsy which was thought to have resulted from the hypoxia at the time of his birth.

Mother D, pregnant with her fourth baby, was planning homebirth with an independent midwife. At 35 weeks, the midwife and D both suspected twins, and D had an ultrasound which confirmed the suspicion. The leading twin was breech. The midwife advised obstetric review, and agreed to support D in her plan for vaginal birth unless there was a clear reason why this would not be safe, and D wanted to change her plan. The obstetricians who D consulted were strongly opposed to any plan for vaginal birth. The midwife then contacted another hospital, where a couple of obstetricians were known to support vaginal breech births, and vaginal twin births (not necessarily at the same time). These doctors also strongly advised D to accept caesarean surgery, and once again, D refused. D was confident that she would be able to give birth spontaneously. She agreed to plan hospital birth in case emergency surgery was needed. D came into spontaneous labour one morning, and proceeded to give birth to her first twin (breech) at 10.30am, her second twin (cephalic) at 11.30 am, and they all went home that afternoon.

Mothers today have many choices, especially in childbirth.  A mother who is informed about the options is able to weigh up the potential positive and negative aspects of any choice that she considers, and reach her own conclusion.

There was no 'informed choice' for mother C.  Undiagnosed breech is a phenomenon that is likely to continue occurring as long as babies are being born.  The point is that midwives and many doctors have been de-skilled in breech vaginal births.  As in this case, the baby needed to be born immediately, and the few minutes delay in waiting for the doctor to arrive may have cost dearly.  In this instance the position of the mother, supine rather than upright, may even have delayed the baby from being born spontaneously.  It's a true story - we will never know what would have happened if.

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