Wednesday, February 6, 2013

decision-making for breech births

In recent months I have been very impressed by the work of a consumer-led group, Breech Birth Australia and New Zealand (BBANZ).  This site has a great deal of useful information and birth stories.  Readers who are interested in being part of the social media discussion on breech births can apply to join the facebook group.

In this context, I have been drafting an information sheet on the decision-points for a woman who has a baby in a breech presentation:

Decision Point #1:      DIAGNOSIS of breech presentation at or near Term

Your midwife or doctor may diagnose breech presentation by palpation, and recommend further investigations such as ultrasound.  Your decision—yes or no—will lead to the next Decision Point.

 Decision Point #2:      ATTEMPT ECV

IF your baby’s breech presentation is confirmed, then you may consider attempt(s) at external cephalic version (ECV). 
After ECV, your baby may be presenting cephalic (head first), or the breech presentation may persist.  In either case, if there is no valid reason to interfere with the natural process, await spontaneous onset of labour.

 Decision Point #3:      PLAN for VBB

Consider the capacity for vaginal breech birth (VBB) at your intended place of birth; the skill and willingness of your primary maternity care team to proceed with VBB; and access to emergency obstetric and neonatal care if required.  Consider the possibility of changing to another maternity service that is more able to support VBB.

Decision Point #4:    Onset of labour

Your midwife or doctor will advise you of recommended ‘boundaries’, such as gestational age of your baby, spontaneous pre-labour rupture of membranes, and changes in your own and your baby's condition. 

Decision Point #5:    Progress in labour

Your midwife or doctor will monitor your progress, and your baby’s wellbeing, as labour becomes established.

NOTE: The wellbeing and safety of mother and baby guide all maternity care.

This list makes it all sound very straight forward, and it should be. 

UK midwife Mary Cronk MBE wrote in 1998: 

These are the points which midwives should bear in mind when facilitating a vaginal breech birth:
  • Don't push a breech through a pelvis with oxytocic drugs
  • No inductions, no augmentations
  • If the labour does not progress - caesarean operation
  • Don't pull a breech down through the pelvis - no breech extractions
  • Breech by propulsion, not traction
  • If it isn't coming down - caesarean operation
  • Keep your hands off - sit on them if necessary
  • Be ready to bag and mask. (AIMS Journal)

In that article, Mary Cronk outlined the features of a breech birth (as distinct from a breech delivery):

Breech birth
  • Spontaneous onset anytime after about the 37th week.
  • No augmentation if labour is slow or there is poor progress - caesarean section.
  • Mother encouraged to assume positions of choice during the first stage.
  • Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
  • Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
  • Membranes not ruptured artificially.
  • Vaginal examinations restricted to avoid accidental rupturing of the membranes.
  • If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
  • Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
  • Mother encouraged to be in an all-fours position.
  • No routine episiotomy.
  • Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

It's clear to me, from a midwife's perspective, that in the journey of decision-making for spontaneous breech births, there are several points at which caesarean surgery would be the next step.  Many colleagues would say, what's the point? 

We will never know if a vaginal breech birth (VBB) is possible unless we proceed down this mystery pathway.  We will never know if labour is able to progress normally if an elective caesarean is performed at 39 weeks.  The avoidance of unnecessary caesarean surgery is of great benefit to the mother and baby, and subsequent children.

A breech birth requires skill, patience, and courage on the part of the woman, the midwife, and the support team.  A breech birth also requires the willingness of the woman to engage in decision-making over time, as the process unfolds, rather than being attached to an inflexible plan for vaginal birth.

A breech birth relies heavily on the ability of the woman's body to intuitively progress through spontaneous onset of labour, and progress in the first and second stages of labour.  There is no room for induction or augmentation of labour, which might mask the natural reluctance of the woman's body to proceed with the birth of a disproportionately large or poorly positioned baby.  There is no room for mind-numbing narcotics which distance the woman from her ability to make a natural response to her labour, and which inhibit the baby's ability to breathe in the moments after birth.  The maneuvers that a midwife may undertake in the moments before the birth, such as gentle turning to release a nuchal arm, or support to flex the head, require confidence in the mechanisms of breech birth and the midwife's skill.

A dilemma we face today when approached by a woman who plans to give birth vaginally to a breech baby is the lack of understanding and skill in spontaneous breech birth in most hospitals.  It's almost a lost art.  Even hospitals where the obstetrics team have indicated 'support' for VBB (more accurately, breech delivery or extraction), the requirement is usually that the woman is in lithotomy position once the presenting part is on view, and that the obstetrician manages the birth.  The baby's cord is clamped and cut soon after birth, and the baby is passed to the paediatric team for resuscitation. 

This scenario contrasts with spontaneous VBB birth: in second stage the woman adopts an upright position (such as 'all fours', kneeling, or supported squat) and her baby is born with minimal touch and without any pulling by the midwife.  The integrity of the cord is maintained, and if initial resuscitation is needed baby is placed on a flat surface, continuing to receive the oxygen-rich placental transfusion from the mother, while the baby's independent breathing is being established.

A second dilemma that midwives face is the discussion on place of birth.  Midwives who understand the advantages to mother in baby in spontaneous breech births are often strongly in favour of home birth.  Yet the implications for the baby particularly, if urgent caesarean birth becomes the birth of choice, mean that there is a real advantage to being in hospital for the latter part of first stage, and second stage labour.  The other matter for midwives to consider is the 'unprofessional conduct' notification that would almost certainly follow a transfer of a breech baby or mother to hospital.  Never mind the woman's choices: midwives are expected to refer women with breech babies to a higher power (Category C in ACM National Midwifery Guidelines, 2008.

In conclusion:
I believe that the process of decision-making in breech births is all about getting the best possible birth for that mother and that baby.  It's not about vaginal birth or caesarean, no matter how much the spontaneous physiologic birth is the preferred option.  If a caesarean is required, then it would be tragic if a caesarean was not available.  

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