Over the last decades, caesarean section has become the method of choice for breech presentation. This article is a reflection on my personal experience as a midwife and my thoughts in regard to questioning the justifications for performing routine caesarean for all breeches

Tabib, Mo

English

Open Access Institutional Repository at Robert Gordon University

TABIB, M. 2013. It's a breech! Midwifery today [online], 108, pages 46-47. Available from: https://www.midwiferytoday.com/mt-magazine/issue-108/     © Midwifery Today Inc. All rights reserved. This document was downloaded from https://openair.rgu.ac.uk It's a breech! TABIB, M. 2013 itIIItIIlt6tO;lffiii'#$;j:*:rThis article is a reflection on my personalexperience as a midwife and mythoughtsinregard to questioning the justifications.forp.ifottning torrtine caesarean for allbreeches'Gemma was a Para 1 with a Previousspontaneous vaginal delivery with no preg-nancy complications who was admitted at40.6 weeks gestation with an undiagnosedbreech presentation. Iwas told Gemmawaswaiting for admission in the midwives'unit'I was also told she had been referred to thehospital by her community midwife.Whenl enteredthe room, shewas sittingon the bed looking terrified, though she wastrying to put on a brave face."I had planned for a homebirth, but mycommunity midwife said baby has passedmeconium and I had to come to hospital'Can I stay in the midwives' unit? I reallydontwant to go to the labourward."I said, "Let me examine you first to seewhere we are and then we'll make a deci-sion together."On examination, the cervix was 4 cmdilated. WhatI could feelwas definitelynotthe head-it was a breech presentation. Ithought, How can I tell her that not only shehas to go to labourward, but she also needs to betaken to theatre to ltave a caesarean? (Crcsarcanis usually the method of choice for breechpresentation in our hospital.)I said, "Everything looks fine, baby isabsolutely happy, you are fine and I thinkyour baby might be breech- Of course thisis not an abnormality, it is just differentfrom the presentation of most babies atthe time of birth." Then mY mind fewback to years ago when I used to work ina very rural area of Iran. At the time I wasa midwife working in a midwife-led unit,where the nearest consultant-led hospitalwas two hours awaY. I was trained toWinter 2013women who had had Prolongedlabour, induction or augmentation,epidural or no skilled/experiencedclinician at the birth, the resultsweresimilar.The follow-uP studY two Yearslater by Hannah et al. 2004 did notshow any difference in the long-term outcomes. HoPefullY, thesesupportive findings will now chal-lenge the practices put in place afterthe original study. (Royal CollegeofMidwive$There is evidence based on other studiesthat concludes, "In places where plannedvaginal delivery is a common practice andwien strict criteria are met before andduring labour, planned vaginal delivery ofsingleton fetuses in breech presentationat term remains a safe option that can beoffered to womeri'(Goffinet et al. 2006)'In the Goffinet et al. studY, thepopulation studied consisted of 8105p..g"*t women delivering singletonietuses in breech presentation at term in138 French and 36 Belgian matemityunits'I thought, Flatrr can I ltelp Gemma to ruakean informed choice? Could my lreaious experi'ence be an infuentialfactor?Being a midwife for 20yeats has givenme the insight not to underestimate the eFfect ofmind on body and, consequently, onthe process of labour. How could I discussthe different aspects and the potential risksin a way that would emPower Gemma tomake an informed choice?Gemmat voice pulled me out ofmy ques-tioning mind, "I have an 18-month-old athome-I want to avoid a caesarean if at allpossible."Now I was ready to share anYthing Iknew.I discussed the available evidence andthe options and explained that ifshe de-cided to try a vaginal birth, there would bea low threshold for a caesarean iflabour didnot progress satisfactorily or ifbabybecamedistressed.Jlt's o Breech!"'- - - - -' - - - - - - -by Mo TabibAuthor,s note: Names have been changed to deal with undiagnosed breech deliveries,preserve anonymity. not because we were supporting vaginalbreech deliveries but because we couldnot get them to the hospital and theatrein time.There were several occasions in whichI had no choice but to assist with vaginalbreech births. Interestingly I had noticedthat progress for these raginal breech birthswas more rapid than a cePhalic presentation'In my expirience, the outcomes for allthese- women and neonates were good'What I had learned from the experiencewas that providing a calm, reassuringenvironment for these mothers was one ofthe most essential factors.This allowed theappropriate hormones to act and for thepelric mutcLs to relax and open (EvansZOLZ). tt moms felt reassured and safe,they would feel confident and would stayfocused and in control oftheir labour.In breech presentation, one of the mainconcerns is dealing with a trapped head'Arxiety and sffess can distract the naturalprocess oflabour and cause this to happen'"In nature, when a labouring animalfeels threatened or disturbed, the sffesshormone catecholamine shuts downlabour. Similarly,when a labouring womandoes not feel safe or protected or when theprogress of her normal labour is altered,catecholamine levels rise and labour slor'vsdown or stops" (Lothian 2004).As a result of my exPerience' I havealwal,s been wondering whether or notcaesarean section i. t oly the best methodof delivery for every mother with a breechpresentation. Especially since the studyof Hun.rah et al. in 2000' caesarean hasbecome the method of choice aroundthe wodd. However, the Royal College ofMidwives made this statement about theHannah et al. study:The study concluded that, forbreechpresentations, the resultswere clearlyin favour ofplanned caesarean sec-tion over planned vaginal delivery.But after adjustment to excludel|idwifery TodoY midwiferytodaY.comIn the end' I added that I would sup- Gemma's labour progressed quickly and 18-month-old at home with little supportport her either way. If she chose a caesar- before I knew it, the cervix was fuily di- for child care.ean I would be by her side, and if she chose lated and baby was on its way out with no Routine caesarean for all breech pre-a vaginal birth I would be quite confident time for a transfer to theatre. We did take sentations also has caused the skills nec-to look after her and deliver her haby. every necessary precaution: a paediatri- essaryforassistingavaginalbreechbirth"What if your shift is finished and I cianwas present in the resuscitatlon room, to be lost.am still in labour?" theatre was ready, and two obstetric reg- "Many midwives have lost, or never"Gemma, IpromiseIwillseeyourbaby istrars were standing behind me in case been..rabled to learn, the skills neces-in your arms before I go home." any problems arose during birth. While sary to assist a woman to give birth when- Following this, medical staffwere in- Gemma was on all-fours facing the wall, the diagnosis has been *rd.. Thi, lack offormed and the obstetric registrar per- she could only hear my calm, ieassuring skllls and confidence continues to driveformed a scan and discussed the options voice, encouraging her that she was do-- the caesarean rate for breech presentationsand potential risks with Gemma. ingamrzirgand that the birth was going even higher and contributesio accidental_ "I would like to try a vaginal birth, well. Gravitywas the best aid for Gernma lnjury of the baby during caesarean de-but if baby gets distressed or my labour and her baby legs flopped out followed livery" (Gaskin ZlOOq.doesn't progress, then I will give consent shortly after by arms. There was about a Gemm a had z positive and empow-for a caesarean," Gemma said. two-minute gap between the delivery of ering birth experience, a natural birih inGemma's decision was respected by the body and the next contraction, but it a safe place and a well-equipped hospi-the medical team. Continuous fetal moni- felt like hours. I assume this is the time tal with medical support. W;uld it nottoring commenced and fetal heart tones that inexperienced practitioners might be ideal to give the same option to otherremained reassuring during labour. After panic and be tempted to start using their women, too?six hours of swaying on the ball, being on hands when there is no contraction pres-all-fours or standing up rocking her hips, ent, whereas with little or no input from ReferencesGemma gave birth gently and quietly to the practitioner, the babywill flex his head Butr"l.l.l "Breech: A Variation of Normat." Homebirth:her healthy ,o, LeIo in the hands-and- andbirth alone as Gemma's baby did. ill;{;,ii,i\,.ti1,i);,[1)Trii;.::f;.1Tfl/lknees position. Leo was 3740 grams (8.25 For a normal breech birth, the -of-normal.html.lb) and had Apgar's of 8 and 9. Gemma time-honoured advice, hands off ''""1,,1;,:,.,,'l?l;_l}i'Jffi,:5::.'rT:r$#: ,ii,#had an intact perineum and only 100 ml of the breech, is still the safest advice. ***.urtt'*ortr..o.zalarticles/midwifery-skittsblood loss. The satisfaction seen in Gem- Keep your hands to yourself; sit on ..,-::"d11-,b:'"'h-birth-marv-cronk.ma's eyes was immeasurable, something them if necessary. old -iJ*ir*y ""ii,i;i91,1;,?#;$#tr'6,tiy*osicar Breechthatwas not considered in the Hannah textbooksshowthatwhenawom- Gaskin, IM. 2004. "The Undervalued Art of VaginaLet al. study. an is on her back for the delivery, il:ili,T:;,1":-"i"'.".'.Tr.tJ''irlT;li:t ffi}iIn fact the only vaginal breech de- the attendants lift the baby up by www.inamay.com/article/undervalued-art-vaginalliveries I have seen in my current work the heels, over the mother's pu- _lliiii;lll.&r1-trr-everv-birth-attendant-shourdplace were undiagnosed breeches. The bis; when she is on her hands and c"m"J.'r, "iiL. 2006. "rs pranned vasinar Detivery rorbreech presentation for these women was knees this movement happens by #:jHJ:,',"jlT*l;il"JL;:1fl"?rlT:I.j::Tdiscovered when baby's bottom was out. gravity (Cronk 2OO7). Betsium.,, Am J 0bstet Gynecor ts4 (4)t 7oo2-1.1..This is always dealt with as an emergency The majority of injuries in cas- Hannah, ME, et at. 2000. "Planned caeiarean sectionsituation: the scary sounds of ,r,-.-"r- es of vaginal breech delivery are fTJ,'J'ilffi1,lTll:jii[[:::if;;:ffi:ji*;gencybuzzer goes on, dozens of medical those caused bypulling or.ieiking Q23s): t37s-83.and midwifery staffwho are complete on the baby's soay m in .ror, ,J "'Xll;,"riit il ','.11;JT"',*,1*Tffi,"r1,f.T;strangers to the woman enter the room hasten delivery (Barrett 2008). v.gir.t-Birtt' for Breech presentation at Term: Theand usually the medical staff takes over The aim ofthis article is not to rycc..r: [t'#T;:::ffiiTilf]T Breech Triar'" /4m Jand starts with a hands-on technique. thatallwomenwithabreechbabyshould ,.,nur,iol'r6oo...Do Not Disturb: The rmportance ofThese wornen are not given the slight- be given the option ofvaginal biith or to _, Privacy^in,Labour." J Peinot Educ 13 (3); 4-6.est chance to trust theii inherent abiiity uniermine the val.re of s,rigery for some of "' i:il'r'J'lf"T-3i#i'#1fi], ;i:JH: i,ff"'lr:l.rT,and deliver their babies in peace or have these women. However, I am questioning zoti. ittp11***.rcmnormalbirth.org.ukl.a positive experience of birth. In fact, it the necessity of elective surgery performed -,.,-:is highly likely that they are traumatised simply because of breech pr"er*irtion. We S€ '" Tabib has been a midwife for 21by the experience. have iorgotten that mani of these women ,X--,J:ult. she graduated from Tehran. Gemma's storywas an exception in our would b"e able to give birth ,,fti;;;: I[fflt}, jiiX;rjl'Jjtr'fi1,j,ll,IXT'Ir1hospital, as the usual practice is caesar- vaginal route. It should be quistioned ;;il;, ,.orLuna. Mo worked as an indepen_ean for breech presentation. Even if the whether calling for routine cu.sarea., fo, ;.,rt ;dffi for 13 years. At present she ismother chooses atrial of vaginal birth, all breeches is the best choice, no mat- a practicing midwife in Scottand, a researchit is usually an obstetric birth in the li- ter what this means for the women 11- midwife for University of Aberdeen and an as-thotomy position in theatre. However, volved, like Gemma, who may have an sociate lecturer for Robert Gordon University.midwiferytoday.com llidwifery Todoy Winter 2013 47

It's a breech!

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It's a breech!

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