A multi-disciplinary hospital meeting to air issues raised by women’s feelings of dissatisfaction with obstetric consultations for breech-presenting babies is discussed by self-employed midwives Margaret Gardener and Jenny Crawshaw. Originally published in Birthspirit Midwifery Journal 2010; 5: 63-67. References updated March 2014.
The New Zealand Guidelines Group’s NZGG (2004) Care of women with breech presentation and previous caesarean section aims to provide accurate evidence-based information to health practitioners, pregnant women and their families about care with breech-presenting babies. The Guideline, containing summaries of the evidence that has been published on risks and benefits of either caesarean or vaginal breech birth in one document, can make it easier to weigh up risks and benefits and make decisions on the ‘mode of delivery’.
The tertiary care unit in Otago, New Zealand, despite this Guideline, does not have any policies for offering and providing breech birth. Women are told that if they come into the birthing unit in labour, there will not necessarily be skilled clinicians on call at the time to provide care and, therefore, the safest option would be a caesarean section. Women planning a vaginal breech birth are also informed that the lack of experience or even exposure to breech birth amongst the clinicians at the hospital can be a significant factor in the standard of care they will receive there.
It is apparent that consultations that take place at the hospital ANC are not inclusive of the New Zealand Referral Guidelines Ministry of Health (2012) as breech presentation is not accepted as only an antenatal consultation. While it is not listed in Guidelines as requiring a labour and birth transfer of care, there is an obstetric assumption that breech presentation is an abnormal presentation and, as such, care is handed over. When the woman ‘fits’ within the criteria for a vaginal breech birth according to the algorithm, the NZGG recommends that an obstetrician be informed of the onset of labour and when active pushing commences but the woman’s LMC midwife continues with her care NZGG (2004, pp. 17-18). If labour progress slows or there is a concern regarding the mother or baby, a consultation is, of course, sought.
There is an emerging women-led trend that has been precipitated by the repercussions of the Term Breech Trial (TBT) Hannah et al (2000), that is, the dis-ease around vaginal breech birth. This article discusses the process started at Dunedin Hospital of trying to resolve women’s expressed feelings of being dissatisfied and feeling unsafe to birth their breech babies in hospital following ANC consultations, as Amy’s above story reflects, and to ease the tension felt by midwives who support women’s choices during breech birth.
What choices do women make?
Women will make a variety of choices when fully informed and cognisant of their options with their breech babies, even with the same information:
- Some are happy to accept the option of an elective caesarean section;
- Others comply to a caesarean, but feel they have been bullied or have no real choice;
- Some women wish to continue with a planned vaginal birth within the hospital setting;
- A subset of the women who wish to hospital birth feel they have no choice but to birth at home because of the conditions stipulated during a consultation in ANC (for example, compulsory epidural); and,
- A few women choose to birth their breech babies at home as a first choice.
It is the group of women who would ideally plan a hospital vaginal breech birth who are the most disadvantaged following the TBT trial. Most are highly motivated and well informed. The attitude they encounter is contrary to providing an atmosphere where they can birth physiologically in the hospital environment. If there is a perceived lack of compliance to a planned caesarean section, women are advised to return to ANC to try and procure the choice that is recommended to them.
Amy’s experience of the obstetric consultation process and the issues generated around the choices made available to her provided the challenge needed to look at what is actually going on for women birthing their breech babies. Amy was angry about her second antenatal consultation where she feels several sections of the Code of Rights Health and Disability Commissioner (1996) were breached.
When the Clinical Director was notified of this, she was concerned about the pathways that had led to Amy feeling that she was unable to safely birth at the hospital, stating “the hospital had failed this woman and [it] could do better for the woman choosing the path less travelled”. The Clinical Director went on to suggest a multidisciplinary meeting to discuss vaginal breech birth in the area.
The multi-disciplinary meeting
The multi-disciplinary meeting was well attended by obstetricians, registrars, and LMC and hospital midwives and went into extra time to accommodate the lively discussion. The meeting was skilfully mediated by the Clinical Director and all parties were given the opportunity to speak without being shouted down or demeaned.
The Clinical Director presented a summary of research that has dictated practice over the past 20 years. An LMC midwife presented an account of the journey a woman takes with her midwife when a breech presentation is confirmed, and the Code of Rights and the conflicting messages given to women. A hospital midwife presented her experience of breech births from early in her career where a breech presentation was viewed as a variation of normal to the present day where breech presentation is seen as an abnormal presentation. A speaker from the Ethics Department presented different ethical theories from the mother’s, baby’s and practitioner’s perspectives.
There was a wide range of experience from obstetricians in the room who had attended many breech births to practitioners who had never seen a vaginal breech birth. Few, either midwives or obstetricians, had attended a breech birth over the last year or two. The midwives who had attended breech births had done so in the community. It appeared that some of the more memorable births the experienced obstetricians had attended were breech births where the outcomes were poor.
A discussion ensued on safety and position for birth. All the obstetricians felt safer if a woman had an epidural and birthed in lithotomy. Most of the midwives felt safer with active birthing and birth in an upright position. One obstetrician did acknowledge that an epidural may mask some problems where a caesarean section was indicated. One midwife pointed out that the women who chose to birth vaginally in today’s environment were well informed and generally were choosing a physiological birth and the women who were prepared to have an epidural and lithotomy position, as a first option, would probably have chosen caesarean section.
The group was then asked to indicate if they were ‘comfortable’, ‘moderately comfortable’ or ‘very uncomfortable’ in ‘conducting’ a breech birth. The experienced obstetricians fell mainly into the comfortable category. Most of the other participants were either moderately comfortable, (but prefaced this with needing more experience), or they were very uncomfortable. Obstetricians who had recently qualified talked of very limited experience, and the accompanying limited confidence. Some of the more experienced obstetricians verbalised reluctance to the point of refusal to attend vaginal breech birth.
At the conclusion of the discussion there were divergent views from supporting woman to have a vaginal breech birth to only supporting an elective caesarean section. While caesarean section is now seen as a relatively safe operation, the midwives were concerned about the implications for future caesarean section. One talked about it as being seen as an “easy option” now but, for the woman with a subsequent pregnancy and requesting a vaginal birth after caesarean (VBAC), she is subjected to an often unpleasant consultation where she is informed of the increased risk of uterine rupture and strict criteria to “ensure the safety of mother and baby”. The language in these consultations varies but the words “dangerous” and “death of your baby” is used, and the ability to practice active birthing is reduced. A lot of the obstetricians present were surprised about this observation. The concerns around VBAC are already being discussed in another forum at the tertiary unit.
There was acknowledgement that a service in the environment at the tertiary unit is not conducive to women who choose vaginal breech birth, but all acknowledged that the best place to birth a breech baby was in hospital with experienced practitioners. How to gain the experience was another point of discussion, and all acknowledged that working with models, though not ideal, was a first step in gaining confidence for the real situation. A couple of options were aired:
- A breech squad made up of experienced practitioners who would be on call for any breech births and take over the care of the woman until after birth; and,
- An experienced practitioner being on call for any breech birth who would work alongside the LMC.
What was not discussed is who is best to attend vaginal breech births. The underlying feeling was that an obstetrician should be involved and present for the birth, usually ‘conducting the delivery’. However, one registrar who had only been in the country and area a very short time said she couldn’t understand, if the woman didn’t want the doctor involved, but she wanted to birth at the hospital, why the midwife and the woman didn’t just shut the door and not involve obstetricians at all. This comment was met by a mixture of stunned silence and nervous laughter, as the last time that happened, an unexpected adverse outcome resulted in the midwife, woman and family being subjected to a process that ended in a High Court action where the midwife was eventually acquitted of manslaughter.
The meeting ended with a plan for nominated obstetricians and midwives to get together to take the matter further. The option of having consumer input was tabled.
Where to from here?
The PROMEDA study Goffinet et al (2006), which showed no difference in perinatal mortality or serious neonatal morbidity between labour and planned caesarean section, concluded that in places where planned vaginal delivery is a common practice and when strict criteria are met before and during labour, planned vaginal delivery of singleton foetuses in breech presentation at term remains a safe option that can be offered to women.
The Society of Obstetrics and Gynaecology in Canada clinical guideline Vaginal delivery of breech presentation Kotaska et al (2009) states that spontaneous or assisted breech vaginal delivery is acceptable when certain criteria are met. Apart from Quebec, “where a significant number of physicians still offer breech vaginal delivery” Lalonde (2009, p.483), obstetricians in Canada are looking at how to make vaginal breech birth safe,and that safety includes issues of consent. As Kotaska (2009, p. 553) states:
Even using the Term Breech Trial alone as a basis for a consent discussion, the current practice of ‘not offering’ women a trial of labour while providing ready access to caesarean section is coercive, especially given the equivalency of long-term neonatal outcome. To offer only caesarean section is ethically and legally difficult to justify if a reasonable alternative is available.
Some women in New Zealand are choosing to birth outside a hospital environment as obstetricians are unwilling to compromise their stance on elective epidurals and birth in lithotomy positions. Discussion and a way forward will be challenging for all parties. However, the SOGC SOGC (2009, pp. 563–564) guideline offers a process:
21. In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective caesarean section, and informed consent should be obtained. A woman’s choice of delivery mode should be respected. (III–A)
22. The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III–B)
23. Hospitals offering a trial of labour should have a written protocol for eligibility and intra-partum management. (III–B)
24. Women with a contraindication to a trial of labour should be advised to have a caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III–A)
All participants of the multi-disciplinary meeting did see the increasing caesarean section rate, now sitting between 32–35 percent in Dunedin, as worrying. One way of reducing this may be to support women to birth vaginally with breech babies but the skill level needs to be increased to meet any unexpected outcomes.
This then follows on as to who is the best practitioner to provide care for women birthing their breech babies vaginally. Obstetricians see a breech presentation as an abnormal presentation, where they need to be fully involved. They also find it challenging to be called in at the last minute for an emergency situation. Midwives see a woman birthing her baby needs to be encouraged to use upright birthing positions and non-medicated coping mechanisms with the obstetrician called only if there is a problem with mother or baby. Development guidelines and protocols will help to clarify these issues.
The woman is the centre of this discussion and has the Code of Rights to support the care she should receive, including being treated with respect and having services provided in a manner that respects her dignity and independence, making informed choices and decisions without coercion and harassment after being given the information in a way she understands. She also has the right to refuse services, and to be provided with a second opinion if the practitioner cannot meet her requests.
The challenge for the group is how best to meet the needs of women planning a vaginal breech birth. Not all women will comfortably sit within set guidelines and these women have the right to have services provided with reasonable care and skill in a manner that minimises the potential for harm and to have co-operation among providers to ensure quality and continuity of services. She has the right to choose who will provide her care and who will be present.
As a result of the TBT there are now only a small number of practitioners experienced with vaginal breech births. How best to utilise these skills is a challenge that will need commitment from these practitioners and some creative solutions so they do not become burnt out. Handing over care to a specialised ‘squad’ may have some merits but does not resolve the problem of practitioners gaining skills in vaginal breech births to assist with an imminent birth with an undiagnosed breech. The woman has the right to consent, (or withhold consent), to student involvement and a student can be defined as anyone in a learning situation. With the small number of women birthing vaginal breech babies there are limited opportunities to be involved in this care. The woman should not be subjected to having many practitioners present for her birth; she is protected under the Code from having to ‘agree’ to other practitioners being present for ‘the greater good’.
Many midwives in Dunedin are committed to moving this process forward but the Clinical Director of Obstetrics and Gynaecology has now left and so some of the impetus has gone.
Perhaps it is time to seriously consider Lalonde’s (2009, p. 484) relevant question in a guest editorial accompanying publication of the SOGC Guideline: “Will it be obstetricians and gynaecologists offering this, or, since many hospitals are not offering breech vaginal delivery, will women rely on midwives to do so?”.