Heads Up! Breech Conference

The impact of choice (panel)

November 10, 2012

Panelists:

• Celine Ouellette (Ontario)
• Ruth Mace-Tessler (England)
• Cathy Harris (DC & Georgia)
• Kimberly Van Der Beek (Los Angeles)
• Benna Waites (England)
• Moderator: Robin Lim

Celine Ouellette is from Deep River, Ontario, 2 hours north of Ottawa. She works in the child protection system. She is the mother of one daughter. When she was 34 weeks pregnant, her midwives discovered her daughter to be breech. By 36 weeks, she went in for a consult. Her midwives told her to prepare to have a cesarean. The midwives she had didn't feel they had enough experience with breech. She was devastated and decided to advocate for a breech birth. A midwife in Ottawa was recommended to her; she spent hours talking about safety, risks, and mechanisms of breech. She tried 2 ECVs, did Moxi, chrio, inversions-nothing worked. By the second ECV, she accepted that her daughter wouldn't turn. She enjoyed the rest of her pregnancy.

At 40 weeks and a few days, Celine woke up and felt a small leak. She called her midwife in the morning. She went to see the midwife in Ottawa; she was given antibiotics for GBS+ and sent back home to her community midwives. She also consulted with an OB who was supposed to be breech-friendly. During their meeting, he told her about a bad outcome in detail. Neither her husband or her midwife were there. She went about her day. Labor had started the next morning, so about 24 hours since SROM (later on in labor, her water broke again, so the first one was either a small leak that resealed or a rupture of one of the amniotic layers). She labored at home until 4 cm and went into the hospital around lunchtime.

The nurses didn't want her to eat, but she was hungry so she did. Around 1:30 pm, the on-call OB (one she hadn't spoken to) recommended Pit in a few hours and then a c=section. She said, "I'm just getting started and we're not talking about that right now." The Ottawa midwife was there but couldn't attend to her because of hospital policy. Celine refused the offered Pitocin. Around 4:40 pm, the OB recommended Pit again, and she agreed to it. She did 2 hours of Pit. A few hours later, she did N2O2. She's progressing slowly. She felt she needed to be on hands & knees and couldn't have an epidural. 

She kept watching the clock, waiting for the breech-friendly OB to come in. He finally comes in and checks her around 9:30 pm. He wasn't comfortable with how things were going and recommended a cesarean because of membrane rupture, EFW was near the upper limits, and GBS+. Her husband was devastated and unable to provide support at that point. She couldn't see any way to do things differently.
Celine asked for a few minutes to think, and she talked with her midwife. She reluctantly consented to the cesarean. The midwife checked her again and said "I can feel a change; I'll be right back!" Celine tried one last time to argue for the possibility of a vaginal birth, but the OB said she was likely to end up with a traumatic delivery and forceps. She knew she couldn't do that to her baby. Even though the midwife had discovered some change in her labor progress, at this point she felt trapped and went through the CS anyway. Her midwife stayed by her side the whole time.

Her daughter wasn't over 4000g. She had the cord around her neck twice, which might not have been a big deal anyway. She feels she would have been fine if she'd been given a fair shot. Care providers need to know that almost 2 1/2 years out, she still can't get through her birth story without crying. It will continue to affect her throughout any future pregnancies. It wasn't just her birth. It was her experience of becoming a mother.

Ruth Mace-Tessler lives about 2 hours outside of London. She had one baby born in 2009. She commented, "It's not so much the actual birth, but the whole picture leading up to that point, that dismays us." She found out her son was breech around 28 weeks. Time passed, and he was still breech. She felt excited: "I like a challenge; I can do this!"

Her sister was very helpful, recommended a doula, and gave her Jane Evans' book on breech. She saw nine different midwives prenatally, so she had no continuity of care. She had to explain over and over the same thing. She had an U/S at 37 weeks at the hospital. She were booked under a consultant who wasn't breech friendly, and she never saw him, just one of his junior doctors. He asked her, "So, ECV or section?" She said, "no thanks." He then presented her with a big list of risks of breech birth. They went home feeling more bemused than anything else.

At 41 weeks, Ruth saw a new midwife who expressed support for her plans. She hit 42 weeks. She was starting to get pressure to have an induction, but she waited and labor began spontaneously. She wanted to stay home for as long as possible, where she felt safe. Nobody else felt comfortable, though. She kept getting unsolicited phone calls from various midwives who weren't comfortable with her plans. They kept telling her all the things that could go wrong-while she was in labor! Every time she'd get a phone call, her labor would stop. Her husband lost it and started crying. At that point, she got a knock on the door; it was another midwife she didn't know who had turned up because she was her team leader. The midwife came into her bedroom. Ruth told her, "At this point, I'm feeling harassed!"

They eventually went into the hospital. The minute Ruth got there, there was a senior midwife who was very experienced with breeches. This midwife was quite wonderful and supportive. At that point, Ruth had been laboring a long time and she was really tired. Contractions started to peter out, and the midwife said, "I think we need to think about other options." Ruth broke down and cried. Her baby's bottom was already beginning to show. They did move to surgery, and it was so for Ruth hard to deal with the contractions knowing that they weren't going to lead to a vaginal birth. She still feels really sad; maybe if she'd gone in earlier on and spent more labor time with the supportive midwife...maybe she'd have had a vaginal birth.

Cathy Harris is the mother of two children and lives in the D.C. area. Her first baby was born in a birth center in Virginia. That was her perception of normal; she knew how wonderful and beautiful birth could be. Her breech birth with her second baby took place when she was living in Georgia. Unfortunately, there were few options for breech there. Her breech son is now 13 months old. For this second baby, she planned on a natural birth in a hospital, since there were no birth centers in her area of Georgia. She really wanted a water birth the second time; "If I can stay underwater for as long as possible," she thought, "people can't bug me." She'a also a childbirth educator, and she started teaching for an OB's office. She really liked the group of midwives & OBs in that practice.

At 39+4 weeks, she discovered her son was breech. In the back of her mind, she had known something was different and had been saying so the last few weeks of prenatal visits. She finally insisted on an ultrasound, and the baby was indeed breech-and a footling. She immediately tried to do everything she could to get her baby to turn. She convinced her OB to give her another week. She met with another doctor and a home birth midwife. A day before her scheduled c-section, she met with her OB and asked for more options, for the possibility of a VBB. They said absolutely not; you have to have the c-section.

The day before, waiting for her c-section the next day, was probably the worst day of her life. She knew what giving birth could be like. She knew inside of her that she had the strength to birth her baby. Her husband didn't even understand it-knowing she was going to have to go in and relinquish all control to people she didn't know. In contrast, her first birth felt like it was hers. Right before the surgery, a new nurse came in and said, "Do you have a birth plan with you? I want to know your original plan was so I know how to help you and so you can be empowered to breastfeed your baby." This gave her a lot of peace during the surgery. She also made it very clear to the people in the room that the surgery was not what she had chosen. After her c-section, she took to breastfeeding the way she'd taken to her first birth; it was what she had control over. That was where she found her empowerment. It was one of the best and one of the most horrible days of her life.

Kimberly Van Der Beek (wife of actor James Van Der Beek) shared her two birth stories recently on a People blog. For her first baby, she'd been talked out of her dream of having a home birth and ended up with a more medicalized experience in a hospital. With her second baby, she found her son was breech at 37 weeks. She was very naive and didn't even assume that meant a c-section. However, her doctor said it was absolutely not possible to have a VBB. She tried everything to turn the baby. Her chiropractor recommended 2 options: one OB who does routine epidurals, inductions and forceps for breeches. Or Dr. Fischbein, who does them at home. She was thrilled to hear that. She listened to everyone's fears, tried to be a reasonable person, and asked questions. She realized there were risks with every choice. You need to know that you're assessing risks vs risks, not risk vs no risk.

A few days after she'd switched providers, Kimberly received an email from her original OB expressing her worries and fears. She wrote to Kimberly: "Your child, I'm afraid, is going to have problems with fetal stress. God forbid, he could die, and I'm very concerned. I think you need to schedule a cesarean for Saturday." This was one of the most natural-friendly doctors in LA writing this letter. Despite these obstacles, her husband was always a tremendous support.

The following Monday at 3 pm, her water broke. Dr. Fischbein confirmed rupture of membranes, checked that everyone was fine, and told her to call him when labor began. She took a bath, spent some special time with her daughter, and went to bed. At 5 am, she woke up with a really strong contraction. They were 3 minutes apart, strong, and long within half an hour. Her doula and midwife arrived-she was 9 cms. (Dr. F was with another laboring breech mom 65 miles away!) Her body began pushing, but she tried her best to wait for him to come. When he arrived, he was very casual and relaxed. He let her go into the zone and do her thing. Kimberly told the audience--specifically the maternity care providers-- "In the future, let us go into our zone." She also noted how being in a comfortable environment helped her find the strength she needed: "When you're in your own bed, with the sun rising, you can go there. You can make it happen." Her son was born at 7:42 am. She concluded by asking, "How can I help this process along? If I can do anything to help, let me and my husband know."

Benna Waites, author of the 2001 book Breech Birth, (I reviewed this book back in 2008) had a breech baby born in 1998. At 36 weeks, the conversations started. He'd been breech for a while, but everyone said "he'll turn, he'll turn." She'd read enough to know that the evidence supported VBB as an option. This was pre-TBT. She'd also seen pictures of an upright breech birth and felt that made sense. Her partrner had passed out while watching a c/s video, so they were both very keen to avoid surgery if they could. The consultant they saw said that cesarean is best for the baby. She disagreed and said her reading of the evidence indicated otherwise. He said, "Okay, but we'll do it in lithotomy and use forceps." It sounded "medieval" to her. It wasn't something she could do.

She went through mourning for the loss of her lovely, peaceful pregnancy. She also mourned for her colleagues. She's a psychologist and evidence-based medicine was a big thing in her field. There was something shocking about obstetricians lying to her. "I was angry, not just scientifically disappointed."
Benna lived on the edge of London and began phoning hospitals and midwives. She also spoke with some independent midwives. Finally, she contacted an OB at King's College Hospital, Donald Gibb, who was known to be progressive. He was really up for doing an upright vaginal breech birth. She described him as "committed and quite keen." But he had lots of international conferences. He said, "I can't guarantee that any other consultant will give you a TOL on all-fours, so I'll come in for your birth as long as I'm in the country." Incredibly enough, she went into labor when he was in the country.

Like many of the other panelists, Benna commented that "It was the struggle that was so important. The birth itself was the most normal, natural, straightforward part of the process." This hospital wasn't the most beautiful place in the world. Her attending midwife (present while Dr. Gibb was on the way) was quite frightened. Dr. Gibb and her partner gave her fantastic support and confidence. Labor went smoothly. Her son was born spontaneously on all-fours in front of a vast audience; she wanted others to observe so they could share that knowledge. This experience set up her journey into motherhood with a cause for celebration, not mourning.

This also spurred her to write the book Breech Birth. It was a 2-year project, finished in 2001. It reviewed all the evidence available about breech birth at the time. Her main message for OBs who only look at the TBT is that "your ignorance and your fear cannot be the reason for our lack of choice. That is not okay."

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