Monday, April 12, 2010

The tears of breech

The Ottawa Citizen heralds the re-newed Canadian acceptance of vaginal breech birth in Elizabeth Payne's article, Giving Birth the Natural Way. Andre' Lalonde, head of the Society of Obstetricians and Gynecologists of Canada, said last year, "The safest way to deliver a baby has always been the natural way," and then began to bring back breech birth to Canadian hospitals.
A young OB attends his first breech vaginal birth and baby Lily's birth becomes a promise of more safe breech birthing in Canada. Betty-Anne Daviss, CPM, highlighted in Payne's article, has been uniquely active in Ottawa, along with Robin Guy of the Coalition for Breech Birth, to educate doctors and parents to safer methods of breech birthing and making them available.

Breech vaginal birth has never been understood in American Obstetrics. Here, doctors neglected to learn from midwives the traditional skills for breech or any form of birthing. In Europe, midwives were brought into the medical model. Also, European and Canadian medical practice actually uses evidence-based research for practice, not just discussion.
That said, the Canadian 2000 Hannah Breech Trial did not choose a research form to accurately show the safety of skillfully attended breech births. Here is what Andrew Kotaska wrote about the Breech Trial in 2005,

"All major advances in technique have occurred in Europe—notable were Bracht's and Thiessen's introduction of a one-phase spontaneous birth resulting in the largest published decrease in perinatal breech mortality.3 4 Experienced European centres showing safety in vaginal breech delivery with these techniques were under-represented in the term breech trial, partly because some declined to participate. In contrast, the term breech trial was based in North America, where the vaginal breech birth rate is a quarter that in Norway or the Netherlands. The protocol superficially outlined a two-phase birth, neglecting techniques that are widespread in Europe and largely responsible for safe success with vaginal breech birth.5 Despite its design by North American experts, and its international vetting (minimally in Norway, Ireland, France, the Netherlands, Austria, and Germany), the protocol represented a simplified and outdated approach, comparatively less safe for achieving a vaginal breech birth rate > 50%. Declaring this standard the best achievable because it was studied in a randomised fashion seriously breaches the limits of evidence based medicine."


Yet, because of both the loss of breech skills in Canada and America and further, because of the 2000 Breech Trial, women here face a dearth of support when their babies are breech. They are gawked and gasped at by friends and strangers, "You're having a breech? Oh, that's so dangerous. You'll have to have a cesarean."

At the Minnesota Baby Expo this past weekend, several women approached me with their breech stories literally crying to be told. The first was a healthy woman carrying two breech twins due shortly. She burst into tears as she asked me if there weren't anything she could do to get her babies' head down? Two more women came to my table with twin singletons. One allowed me to have pictures taken while we went through a home, self-care breech protocol - things she could do herself at home to help balance her pelvis. I hope to post these photos on the breech section of SpinningBabies.com

My body shakes and my brains sag in their sac recalling the mother who asked me if I'd ever seen a baby cut during a cesarean? Anticipating bad news, I quietly said I had heard of it. Of course, I wondered if the sweet, tiny baby she held by her heart was the baby she meant. But she turned and pulled up her shirt and told me of how when her mother came to the hospital in labor with her, the doctors discovered her baby, the woman now before me, was breech and they rushed her to surgery. In performing the cesarean section they cut her back open. The scar was surprisingly deep, long and puckered. She herself had been that sweet, tiny baby, trying to go about her birthing business and being cut right out of the womb. In this instance, literally cut. Newborns generally heal so well but this scar is broad and deep that I think, she must have been cut to her ribs! As she finished her story our eyes locked, frozen in mutual astonishment. Though she has come to terms with it in her way, telling it to someone who is comfortable with (physiologic) breech vaginal birth allows the absurdity of slicing into a rapidly progressing breech birth to be seen for what it is. She was less than 6 pounds when she was born. I hope she contacts me again, I didn't even get her name. She promised to send me a picture of her back next time she was pregnant! I hope she does! You should be confident in the truth of her story.

In all sincerity the breech twins mother tells me through her tears, "I'd do anything not to have a cesarean, but since its my first pregnancy, and perhaps if they weren't breech, well, I might have a homebirth , but you know, I don't want to do anything that isn't safe..."

The suggestion of changing obstetricians was also frightening to her. Once the stress is super high, women often won't do anything not to have a cesarean. Is this the strategy of the old boy's club?

Dr. Lalonde is quoted, "Vaginal births are the preferred method of having a baby because a C-section in itself has complications." He spoke eloquently for natural birth, and especially, natural breech birth, at the Ottawa Coalition for Breech Birth conference last October.

Women will accept the risks of cesarean section because they believe these risks take place in a controlled environment where they can be handled successfully. They don't think they can happen to them. They trust the recommendations of their doctor.
They have met and developed a relationship with the doctor, and even if the doctor makes her cry every time she leaves the clinic (women have told me that they do), she's put her trust in the persona of techno-surgical, medical authoritarianism (because, hey, it isn't evidence-based fact).
We tend to go with known dangers than trust the unknown. We tend to accommodate the person we see as most powerful rather than the person with the facts. Women have told me they won't leave their doctor because their doctor may get mad (I'm not kidding you), even to go to another doctor. Even to see a doctor with a good reputation and community praise...

Unless that woman has an inner strength to connect with her truth, a trust in the Divine, a trust in the Design. Support from her mate and a guide of some sort (doula, midwife, childbirth educator) to lead them to the person and place they can give birth with safely.
Really, it isn't whether she had a cesarean or a vaginal birth, home or hospital, that is the most important individually, but rather that she is heard and respected and nurtured while she brings in her child. Being surrounded by fear and ignorance during childbearing is not empowering whether or not you have a homebirth or a cesarean. I'm not into ideology either way. Every birth is different and each situation needs assessment before and during birth.

Giving birth to a breech baby vaginally, while in the knee-elbow (or hands and knees) position has been shown to be the safest. Safer than cesarean section as long as the labor is progressing normally, as long as the person attending knows the set of simple maneuvers to free trapped arms or to flex an extended head. As long as no one touches, turns, or otherwise surprises the baby who is birthing spontaneously.

Its ok to rescue a stuck baby, of course. The proper methods are simple if the entire physiological "method" is honored!

Right now, it may be as safe or safer to do this at home in America, if the midwife attending will go with such breech birth guidelines as recommended by UK midwives, Mary Cronk and Jane Evans.

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Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.