Thursday, February 14, 2013

Taking calls for breech

The phone is ringing today. Four calls about breech births. The first was a doctor friend who heard a rumor of a bad outcome to a homebirth baby. Did an inexperienced midwife go too far? A Pediatrician told her the baby left NICU with "neurological problems that would last their whole life." Noting the time frame, I realized the midwife in this story was me. Due to premature separation of the placenta the baby had a hard start, spending a few difficult days in NICU. However, he went home 100% -without any detectable problem.

I put in the next call to double check on this baby, in case something came up in the last couple of months which I didn't hear about. Baby is doing great, a happy camper - cooing, drooling and smiling appropriately for the age. He's on track with mental and physical health and milestones tested regularly with current infant developmental measurements as part of a community program the family takes advantage of.

We know from Hannah, PREMODA, and other studies that professional third-party observers can not find increased harm or development delays to breechlings born two years earlier. While a baby in either the cesarean born group or the vaginally born group may sustain injuries or even death, how often this happens doesn't favor one method of birth over another. Other things, like gut flora, make vaginal birth preferable for those babies and mothers that don't have a medical reason to go cesarean.


Hard starts happen. Hard endings are harder.


The next set of calls connected me to a far away care provider whose working with a family whose baby isn't expected to live many days after birth due to an anomaly incompatible with life off the umbilical cord. So sad. The parents would like to avoid separation at birth so they can hold and be with their child every minute possible. The OBs want a vaginal delivery with extraction and forceps and the Family Practice Doc would like a more gentle, physiological breech birth. The OBs rule, though, UNLESS the mother exercises her informed dissent.

Avoiding a cesarean or forceps breech birth is likely to offer a comparitively better quality of life for this child, as short as it may be. There is interest in physiological breech birth on mother's hands and knees to reduce the need for complete or partial breech extraction. Perhaps my words will impart some trust and calm for this care provider so he can meet the needs of this family. If he calls.
In my opinion, this mother will be "allowed" to avoid the risks of cesarean to her because the hospital staff are less afraid of causing death or injury to a child who will, sadly, start dying after birth from natural causes.

Cesarean is associated with a broad set of side effects that the baby and mother will experience. Vaginal breech birth may cause a certain set of side effects that the baby may experience if born vaginally. Its the choice between may and will. We think the side effects of the cesarean end with discomfort and long recovery time compared to vaginal birth. Most side effects of either type are not severe, except, we are discovering, the reduction of beneficial probiotics due to cesarean delivery could cause lifelong immune compromise. Rare side effects of cesarean are severe, chance of death of the mother then or later, and chance of death of a subsequent fetus is higher. Due to the increasing cesarean rates, we also have increasing deaths. Women have the difficult choice of choosing one set of risks over another, but there is no option to choose No risk over some risk. Both ways carry risk.

The fifth call came from across the country from a midwife I adore whose been working with a first-time mother carrying breech. She'd introduced the mother to Obstetricians who had given her an MRI and were willing to help her with a vaginal breech delivery in the hospital -if one of them were on-call and available when she went into labor. They planned to do a partial breech extraction and then show the residents how to apply piper forceps to baby's head during her birth--A standard American Breech Delivery in a teaching hospital. The mom chose to exercise informed refusal and went back to the midwife and asked for help with a home breech birth. The midwife called to chat about it. She's got a breech experienced midwife coming to join her birth team, but just wanted to discuss some things with me.

Being a practical person, I asked a few questions and presented my point of view.
I like to know

  • Mom's determination level is high
  • Baby's approximated size in relation to mom is a fit
  • Baby's favoring the mother's right, even  RSP is reassuring as a starting position 
  • Hands and knees and air birth are preferred for the early breech experiences of no or low- experience midwives - even though an experienced midwife is attending (which is so highly recommended as to be mandatory if such a midwife lives in your 100 mile radius).
  • Frequent monitoring, as much with a fetoscope as possible to keep doppler to minimum because the side effect of secondary noise tends to cause the "Ultrasound wave" which means an arm could possibly be swept up, Jane Evans' observation) but monitor with doppler if fht can't be tracked with fetoscope due to midwives's lack of skill or dense muscles of abdomen or uterus, maternal fat, or placenta blocking the subtle sounds of fht. I'm getting into too many details...)
  • No touching, not the mom or baby unless baby needs help due to stuck arms or head
  • No breech extraction or partial extraction (increases chance of needing resuscitation)
  • Which means, no reaching up and pulling down a leg, etc.
  • Stalls in active labor or second stage (beyond an hour or two) = transport. Yes, even if that means a cesarean. 
  • Internal exams optional, but recommended when there is time, a check upon arrival, if labor seems slow, to assess complete dilation or if labor sounds and progress don't match, or transport is being considered.

And more details were discussed about freeing breeches who get their arms or head stuck, poor little dears.

I hold the families and midwives in my heart and mind every day. Most women accept the current recommendation to have a cesarean surgery to deliver their breech baby. They want what is safest for their child's birth. Few physicians, or even midwives, today will tell the woman that there are risks to both cesarean and vaginal breech birth. But this information can be found from reliable sources, such as the Society of Obstetricians and Gynaecologists of Canada.

Should women choose the set of risks for vaginal breech birth or vaginal breech delivery (partial extraction) ? That is an individual decision based on her body and her baby and the people and resources she has around her. Some women will travel to where a skilled provider is willing to care for her during her birth. We have so much more to discuss on this.

Midwifery Today will carry the discussion in their upcoming breech issue of Midwifery Today Magazine. Sit loose, its coming!





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