With many of Michigan's CPMs slated to attend the Breech Birth Coalition's annual conference in Washington D.C. this November, it's time to start talking about breech birth at home. Women in MI, and elsewhere must be more informed than we were. When a woman is faced with a breech positioned baby at the end of pregnancy, it's very difficult to really "research" effectively. It's easy to listen to what a trusted care provider is telling you, and see only through a lens that supports those notions. Before you consider a vaginal breech delivery outside the hospital, please check out these resources and clarifications.
We have talked a great deal on this blog about the concerning, variable training for becoming a CPM. The fact that a midwife, of any credential (CPM/CNM or otherwise), would even consider a delivery as high risk as a breech delivery at home should be an enormous red flag. No midwife, without an immediate medical facility, and physician presence, is prepared to properly attend a breech birth. In fact, in other countries like Europe and Canada where midwifery is an integral part of their medical system, there are explicit guidelines for risking out mothers with breech presenting babies from home birth. It's a very high risk delivery that sometimes needs immediate emergency care and extremely close monitoring. These countries have determined that screening women to determine who is low risk/high risk, is the most appropriate way to a) keep babies and mothers safe, and b) prevent tragic outcomes. Research was done directly because of the fact that women in Canada were choosing home birth for breech birth because they didn't feel they had options. Canada's response can be found here.
"Women in Canada and abroad are requesting the option of breech vaginal delivery.
Will it be obstetricians and gynecologists offering this, or, since many hospitals are not
offering breech vaginal delivery, will women rely on midwives to do so? Some women
offering breech vaginal delivery, will women rely on midwives to do so? Some women
with a breech presentation elect to deliver at home because they believe they will be
refused a breech vaginal delivery at the hospital. It is urgent that we take on this
responsibility and that every hospital in Canada offer safe breech vaginal delivery. We
need to meet with our colleagues in midwifery to support their request for breech
vaginal delivery in hospital and access to consultation with their obstetrician
colleagues. We cannot condone home breech vaginal delivery; thus, we
must offer breech vaginal delivery as a safe alternative in our maternity
hospitals."
vaginal delivery in hospital and access to consultation with their obstetrician
colleagues. We cannot condone home breech vaginal delivery; thus, we
must offer breech vaginal delivery as a safe alternative in our maternity
hospitals."
I want to be clear that having a breech presenting baby doesn't mean that mothers in the US, cannot aim for a vaginal delivery in the hospital. Doctors in the US willing, and with enough experience to attempt a breech trial of labor, are harder to find, but they do exist across the country. In Canada, they explicitly state that women need to be informed of all
risks, and not abandoned should they make a choice that differs from a
physician's recommendation.
A "Trial of Labor" for a vaginal breech delivery is very different from automatically scheduling a cesarean. It's is also very different from a midwife stating, "recent research supports vaginal breech delivery, I could delivery your baby at home...or at our freestanding birth center." The research she's likely referring to is a 2009 study by the Society of Obstetrics and Gynecology. If you read this Clinical Practice Guideline, you will quickly learn that this research was explicitly written to take place in a hospital, with an obstetrician, and an operating room present.
What exactly is a "Trial of Labor" then? A trial of labor refers to an attempted vaginal breech delivery given very specific safety guidelines. Those guidelines begin with proper evaluation of candidacy before labor even begins. An ultrasound is necessary to determine important factors such as baby's estimated weight (no less than 5.5 lbs and no more than 8.8 lbs are considered qualifying), fetal head attitude, cord position, type of breech position, etc before determining if a woman and her baby meet the criteria for a trail of labor. There are other factors in determining candidacy outlined in the SOGC's research. If mom and baby meet these criteria, then fully informed consent about the risks of both a cesarean and a vaginal breech delivery must be addressed, and documents that show record of such informed consent are signed.
The SOGC research further specifies guidelines for managing labor and delivery with a thoroughly experienced physician on hand. Some of the highlights include immediate pelvic exam upon waters breaking, active pushing in labor should not exceed 60 minutes, and continuous fetal heart monitoring, among others. Another critical note named in this guideline is for a health care provider current in neonatal resuscitation to be present.
For more information about the SOGC's recommendations, visit this link to their brochure on the topic for public education.
If a woman, and her physician, have closely evaluated her candidacy for a vaginal breech trial of labor, then I see no reason not to support that effort inside hospital walls, where emergency care is immediately available. The notion of CPMs, or anyone else for that matter, attempting this kind of delivery in the home setting is disturbing. The fact is that area CPMs are attending a conference held by an organization who, as they put it, "...are not medical professionals," but are instead, "well read mothers and families." Their aim is to learn more about delivering breech babies in the home setting, as if there were no other options. This speaks volumes about their intentions, their misunderstanding of what the medical world can offer, and their lack of appreciation for the risks involved in this kind of delivery.
I sincerely hope that women can sift through the muck, the misinformation, the misguided relationships, and the agendas to see that if a vaginal breech delivery is what you seek, there are safe ways to go about it. (And that is not outside a hospital) If you're in the hands of a responsible midwife, who appreciates safety, she'll help you find a physician that will work with you on determining whether a trail of labor in a hospital is a safe option for you. (If your midwife tells you breech presentation is just a "variation of normal" and she can handle it, find yourself an OB immediately.) There has been good research on this topic as noted here. I hope we can learn from Canada to first see that home birth is not a safe way to delivery a breech baby, and second that our hospitals, midwives, and doctors will continue to work together to best serve the women that need them.
Practicing medicine without a license is illegal right? Is there any way this conference can be closed down?
ReplyDeleteIn the US it is very difficult to find any doctor that will perform a breech delivery in hospital, because of the evidence that a vaginal delivery has higher mortality and morbidity rates. There is some evidence from Europe that for a very select population of breech positioned babies, that vaginal delivery has nearly the same mortality as cesarean. It still has higher morbidity but there may not be long term consequences of that morbidity. Very strict guidelines need to be used, however, as per the SOGC and European authorities, and vaginal delivery will be the exception rather than the rule for breech babies. As cesarean rates for breech went up in Europe in response to the Term Breech Trial, mortality rates among breech babies went down, because the health care systems were being much more selective about which pregnancies got a TOL.
ReplyDeleteI think there'd have to be some significant medicolegal reform before we see breech vaginal delivery make a big come back in hospital in the US. Still, that doesn't make breech delivery out-of-hospital magically safe. The evidence is that breech delivery is risky and dangerous, and that careful monitoring and management is needed.
My MEAC education requirements included writing up informed consent documents. This was challenging because there was huge pressure (not so much from the school, but from my preceptors and midwifery community) to abide by the 'informed consent' doctrine - which meant, essentially, to risk out nothing, but just to providing some sort of information so the parents felt they were educated and informed on the subject.
ReplyDeleteI don't remember what I wrote specifically about breech birth - something wishy-washy, I'm sure. But I've been thinking lately about how I would provide informed consent - how I'd really like to do it - not how I was expected. It would go something like this:
___________________________
"- Your baby is breech, and as a midwife, I am not qualified or trained to attend vaginal breech births.
- There are increased risks of vaginal breech birth due to the position of the baby and the risks are further increased when the birth occurs distant to skilled medical services, and/or under the care of an untrained provider.
Options:
- referral to one of two local physicians that attend vaginal breech birth - this requires screening and evaluating the appropriateness of vaginal breech birth.
- referral to a physician for planned c-section
In interest of informed consent:
- Out-of-hospital vaginal breech birth is not prohibited by law in our state.
- There are midwives who attend breech births in out-of-hospital settings.
- There is no requirement for midwives to be trained in breech deliveries in order to attend breech birth at home.
If a planned OOH vaginal breech birth is desired, despite the increased risks, you are free to terminate care with me and transfer your care to another provider. I do not make recommendations or referrals for OOH breech providers."
____________________
Maybe this language isn't strong enough - but my experience is that clients usually trust their midwives. And I would *much* prefer to referring one of my clients to a physician with training and skills in attending breech birth (as well as c-sections), than seeing them attempt a breech delivery at home. But it is not illegal where I live - and midwives are doing it. I don't want to lie about that either. I feel like I lose credibility if I'd conceal that there are midwives attending breech birth at home. Sure they do.... but they aren't trained to do so... do you want to take that chance? Between a CPM who has attended 3 breech births and an OB/GYN who's attended 100, which one do you want? Isn't this informed consent?
What I've noticed about the midwives who attend breech at home is they usually offer NO alternative - no referral to a doctor who does breech. They lay it out as "gentle home birth with us" vs. "traumatic, risky c-section with the evil MDs."
Surely this is not informed consent.
No, what you describe these midwives as doing is not informed consent at all. It is manipulated consent under the guise of informed consent, and it will simply be used to turn around and insist that it was the parents' choice when a tragedy occurs.
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