Heads Up! Breech Conference

Breech birth at home: Considerations, safety, & informed choice (panel)

November 10, 2012

Panelists

• Mary Cooper
• Diane Goslin
• Stuart Fischbein
• Jane Evans
• Moderator: Ina May Gaskin

Mary Cooper mostly works with 5 Plain communities: 3 Amish and 2 Mennonite. She also serves "English" moms. It's very important to share with clients what a breech birth means. They also need to read up more about it on their own. She demonstrates breech births to her clients with a doll & pelvis. Because of her client population, most of her moms think breech is simply a variation of normal. There's also less fear associated with breech among her clients. She has a few supportive doctors who will do VBB if the mom is a multip.

She tells her moms that the labor will be different than a head-down baby and that she will sit on her hands and not do anything until the very end. She might ask them to take a different birthing position if something is not going well, otherwise they choose the positions they prefer.

She has a very good relationship with a local physician and hospital, so when she transports, they have everything ready for her. You have to listen to your moms. There might be residual fears left over from previous births, so don't be surprised by emotional ups and downs during labors. Carefully observe the mother and baby and use your own skills. 

She's done 59 breeches and transported 3 of those.

Diane Goslin has helped over 6,000 babies come into the world. She works in Lancaster, PA. She serves both Plain (50-60%) and English communities. She has always offered VBB because her community also considers breech a variation of normal. Hospital birth is largely not an option for most of her clients due to finances and lack of health insurance. Many also plan very large families, so CS is not an option. She has become more comfortable watching the process unfold and has become more hands-off over the years.

She has a higher anomaly rate among her Plain communities (because they do not seek prenatal ultrasounds generally) and a resultant higher rate of breech babies. During prenatal visits, she explains the mechanics of breech and goes through the birth process with a doll & pelvis. Over 30 years, she's transported two vaginal breeches, both at the mother's choice. One was for an elective cesarean, the other for a transverse second twin.

If we start a breech, we finish it unless complications arise. They've had a good number of incomplete & footling breeches. They get many primip breech referrals. They follow the mother as she moves and chooses different positions.

Most of her moms consider breech a variation of normal; they've watched animals give birth and are comfortable with the mammalian birth process. The key advantage of birthing at home to her mothers is they're not bringing fear into the birth environment. They supporting and encouraging their mothers. She occasionally dismisses students who bring too much fear into the room.

We need to be able to recognize when intervention is necessary and what to do. It's good to work with other midwives to share knowledge and experience. She asks midwives to come along with their referral clients.

When she started attending births in the late 1970s, she went to a birth solo and the woman's baby was presenting breech. She applied what she'd learned about ECV and turned the baby. She put on the husband's back support belt in place to keep the baby positioned. That was her first breech experience. She's done many external versions at home with careful monitoring & listening.

Because most of her clientele considered home the natural place to give birth, they had to facilitate a lot of their desires for VBB. And because so many of them would have large families, she didn't want to "wreck their career" by starting off with a cesarean. They also had the time to progress at their own rate. They found many primips would take a long time to come down. As long as the mom had energy and baby was doing well, they saw no reason to hurry the process.

Her clientele's babies start out at 3500-4000g or above; she has a Germanic population with large pelvises and large babies and they've had good outcomes all around, breech or head-down.
The inherent risks of breech are inexperience and fear. Her job as a mentor and preceptor is to give other midwives as much exposure & experience as possible in an environment free of fear. Would most of her clientele choose a hospital birth if it offered VBB? Not the Plain population, but many of her English referrals coming in from out of town would definitely go for vaginal breech birth in a supportive, relaxed hospital environment.

Stuart Fischbein is a referral source for practitioners in the LA area; most of his breech clients he doesn't meet until late in pregnancy. His initial visit is 1 ½ hours; subsequent prenatal visits are 1 hour. He works under more of a time crunch with his breech referrals. At a time when there should be peace & calm in a woman's pregnancy, there's lots of turmoil. He reviews their history and if they fit the criteria, he reassures them that there's a good chance of success. Breech labors progress or fail for the same reasons that head-down labors progress or fail.

He gives his clients evidence-based articles to read, discusses the TBT, and explains why most area doctors do not support VBB. Of his 7 criteria, the most important one is having the "right mental stuff"

• EFW 2500-4000g
• Flexed head
• Frank or complete
• no major fetal anomalies (uterine anomalies are not a contraindication, although he keeps an eye out for increased risk of retained placenta)
• wait for labor to begin
• baby has to tolerate labor
• woman has the right mental stuff

Why is he doing home births? He never would have thought that he'd be doing this. When he finished residency at Cedars Sinai in 1986, it was the busiest hospital in country with 22,000 births/year. They saw everything: breeches, forceps, class IV heart disease, etc. He came out of there with really good training. After he was done, midwives approached him to be a backup physician, and he agreed. For 10 years, he backed midwives and then started a collaborative practice with CNMs in Ventura County. 

After about 15 years there, the environment became very hostile. Both the pediatricians and anesthesiologists gave his practice a hard time because his patients didn't want Vit K, bottle feeding, mother-baby separation, early cord clamping, etc. Eventually the midwives were banned from attending births at the hospital for a year. Then the hospital forbid him from doing VBACs and breeches. He could have hired a lawyer and tried to fight the administrative process, which is a losing proposition and costs a fortune. At the same time, he was asked by midwives if he'd be interested in doing home births. He thought for about a "nanosecond" and then said yes. He was fortunate to have that option, and he's never looked back. He doesn't miss the craziness and micromanagement of the hospital environment.

There is a place for home birth. He hopes that physicians will consider this as an option down the road. His eventual goal is to build a regional center for breech deliveries. But for now he can offer people a choice in a home setting, although finances can be a challenge. 

He's very quick to tell people if they're not a good candidate. He's not trying to be a hero; safety is the utmost issue.

Jane Evans worked with the NHS for 20 years before becoming an independent midwife (IM). The NHS became more and more restrictive and compromised the care she was able to offer women. IMs are still scrutinized and judged for their profession.

She spends a lot of time talking through the options, the risks, and the parameters of safety. It all comes down to informed decision-making. The woman has to make the decision for that baby, that pregnancy, for her family and for herself.

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