From MIDWIFERY MATTERS, Issue No.114 - Autumn 2007
Mia Davies
"YOUR BABY'S BREECH". Who'd have guessed what those three words would lead to? Well, the short answer is: anyone who works in a hospital knows exactly how a diagnosis of a breech baby can result in unmeasured chaos, negotiation and compromise. I was naive. As a caseload midwife, I thought that I would be able to give my woman an informed choice and then carry out her care according to her wishes. How wrong I was.
My colleague, Karen, saw my client, Fay, on Tuesday, on a day I was supporting another colleague of ours through knee surgery. She was 41 weeks and 3 days, having come in for a sweep and to discuss what she wished to do about an induction of labour. Fay is from Somalia and wasn't keen on the thought of induction, which was fine with us. The plan was for Karen to give her a copy of the NICE guidelines and, if she chose not to be induced, to book a scan for 42+ weeks to look at Dopplers and amniotic fluid levels. However, on palpation, Karen was unsure what position this baby was in. Fay agreed to a sweep and her cervix was favourable, easily admitting a finger, but Karen was immediately suspicious of the soft and squidgy 'head' that she was feeling, so decided not to sweep and to investigate further. They ended up doing a scan, which confirmed that it was indeed a bottom.
Fay's consultant then became involved. His answer was simple: book her in for elective caesarean section on Friday. But Fay threw a spanner in the works when she told him that she didn't want to have a caesarean. I beg your pardon? Eventually, after much strong negotiation by Karen, he 'agreed' to her having a vaginal breech birth and advised her to have an epidural. Karen, new to the hospital and wary of making too many enemies, let this one slide while in the room with him, but discussed it further with Fay afterwards; Fay decided she didn't want an epidural and would prefer to have only midwives, preferably me and Karen, in the room when she gave birth.
This is where the fun really started. Karen had seen two breech births, both very medically managed, and I had seen a grand total of none. I had, however, attended plenty of study days, practice sessions and the ALSO course, as well as Mary Cronk and Jane Evans' study day, 'A Day at the Breech'. I also spent my elective placement when training with Mary and had helped her reorganise all her breech birth Powerpoint presentations. My belief in a woman's ability to safely birth her breech baby was strong and I was confident that I was up to the job. As it turns out, practically everyone else disagreed with me.
The following morning, at 6.30 am, Fay called to say her waters had broken and there was meconium. She was also contracting mildly. Although the fact that she was post-dates and the baby was breech were both potential explanations for the meconium, I asked her to meet me on the labour ward so we could check the heartbeat. By the time I fought my way through the traffic to get there, she was already in a room on the high risk side of the ward, CTG in situ (perfect trace) with a registrar in the room, doing a vaginal examination. Fay was found to be still in early labour (With mild and infrequent contractions for the past hour? What a surprise!) with a cervix that was similar to the previous day. A scanner was brought in and the registrar decided this baby was Left Sacrum Transverse, with extended legs and documented, for some reason, that there was 'no cord above the neck'.
The registrar then began to exert pressure, bringing up the subject of epidurals.
"Fay does not wish to have an epidural," I informed him. He shot a contemptuous quick glance in my direction before asking the couple if anyone had explained the benefits of an epidural to them? They said yes, but that they didn't want one. He took this as a challenge and started talking about how an urge to push on a not-fully-dilated cervix could cause the breech to descend and trap the head. But, I asserted, that is much more of an issue with a premature baby, where the head is larger than the body, whereas in a term baby they're roughly the same size. Another contemptuous look.
"And what about the side effect of epidurals slowing down the contractions," I continued, "I mean, it's not like we can put up synto on a breech!"
"Why not?" he asked.
"It's not safe to augment a breech," I ventured.
"I disagree with you on that point," he said.
"Well, then I disagree with you right back," I retorted.
Throughout the rest of the day, despite my best efforts to keep them at bay, a seemingly never-ending stream of doctors popped in uninvited to: "Do a quick review", or "Have a quick look at the notes," or "Just come to say hello." Each and every one had their own, often conflicting, views on proceedings. The (very scary) labour ward consultant was next and she decided to repeat the scan because she wanted an estimated fetal weight, and to confirm that there was no cord around the neck, rather than 'above' it, as had been documented, quite possibly erroneously, earlier. This time the baby was found to be Right Sacrum Anterior - the opposite way round from the previous scan - and they estimated the weight at 3.5kg, which did at least seem to make them happy. The consultant asserted that it was 'very very important' for Fay to remain on the CTG continuously, but then complained that the contractions weren't very strong and that she needed to mobilise. Hmmm. Was she suggesting she should dance a merry jig around the machine? We had already been using the birth ball so Fay continued to use that while I conspired to find a loophole to discontinue the CTG. The fact that she wasn't yet technically in labour was just the ticket and, much to everyone's apparent disgust, we took it off so she could walk up and down the stairs for a bit.
Then the pressure to oust me as main carer began. The labour ward consultant quizzed me on my experience with breech birth and, upon learning that I had no direct experience, insisted that a doctor be present for the 'delivery'. I explained that Fay did not wish to have doctors present but that I planned to find an experienced midwife to help me (admittedly a tough call in our unit). The consultant then took herself back into the room, told Fay that I had no experience (which she already knew) and I would have to have a doctor supporting me - okay? Fay, unsurprisingly in the face of what appeared to be a done-deal, agreed.
Next in was a registrar, who is well known in the unit for being egocentric and misogynistic, as well as asserting his own, often wild and unfounded, theories as gospel. Surprisingly, things went well at first. He accepted that Fay didn't want an epidural; he agreed that induction/augmentation was inappropriate with a breech; and he even seemed mildly intrigued and relaxed about birthing on all fours. Then I happened to mention that Fay had had an FGM (female genital mutilation) reversal at 16 weeks pregnant.
"May I ask you a personal question?" he asked the couple. Without waiting for a response, he went on
"When you got pregnant, did you have full penetrative sexual intercourse, or did you" - oh and I swear to God this was the exact phrase he used - "just deposit your seed on the outside of her vagina?"
The couple looked confused. As well they might; I was pretty confused myself. He repeated it several times, continuing to use the frankly ludicrous phrase 'deposit your seed'. I felt desperately uncomfortable but had no idea where this was going. Eventually, after a bit of a discussion, the couple, still clearly confused, said "Outside?"
"Ahhh" said the doctor, looking smug, then turned and left the room. I followed, to try to work out what that was all about. Outside the room, he turned to me and his SHO and said.
"If she's never had penetrative sex, how do we know how big her vagina is?"
I was absolutely flabbergasted. So much so, that I completely failed to challenge him.
I made the mistake, at one point, of going to the loo. And what happens when you leave the room for a couple of minutes? Another doctor appears! This one had been and gone by the time I got back, taking with her the article on 'Midwifery Skills Needed for Breech Birth' by Mary Cronk that I had given to the couple. I found her sitting and reading it by the midwifery station and prepared myself for the worst. She was, however, reading out parts of the article out loud, such as "breech babies should birth by propulsion NOT traction", then saying "I quite agree!" "Keep your hands off a breech that is birthing spontaneously - sit on them if necessary! Oh that is absolutely right!" Maybe this one will be okay, I thought. I approached her and introduced myself, as we'd not met before, and it transpired she was a new consultant. The only thing in Mary's article with which she took issue was the all fours position because, as one would probably expect, she was only used to lithotomy. She expressed concerns around flexion of the head in all fours, so we got a doll and looked at the mechanisms together. She seemed dubious but game, so I asked her if she would be the one to come and support me for the birth: a move I later came to regret bitterly.
Meanwhile, Fay was quietly and calmly getting on with business of getting herself into labour, standing in the corner of the room, hugging the furniture with each contraction and barely making a sound. I made the mistake of telling the consultant when we planned to reassess and, shortly before that time, she came to me and said that she wished to do the vaginal examination (VE) instead - so she could make a 'full pelvic assessment'. I said I would speak to Fay and see what she wanted. Fay made it abundantly clear that she wanted me to do the examination, and I conveyed this information to the consultant. The consultant, all smiles and condescending tone, explained that she wanted to know exactly what she was letting herself in and that it was all about her own 'comfort zone'. I said that I would give consideration to her pelvis when I did the VE and let her know if I had any concerns (although I already knew I did not). She retaliated by asking me exactly what I would be feeling for when I did a pelvic assessment and what measurements I should hope to find. I found myself going red, while I blustered through a response about ischial spines and pubic arches, receiving a detailed and patronising lecture in return. Despite this, I managed to keep her out of the room while I did the VE, whereby I discovered that Fay had progressed beautifully to 7cm.
My previous argument against continuous monitoring in early labour was now null and void. I talked to Fay about the CTG and explained why it was being recommended by the doctors but that ultimately it was her choice. She chose to go back on to the monitor and continued to stand and hug the furniture. By then, Karen had arrived to relieve me for a break so I eagerly took the opportunity to rush down to my spiritual home, the birth centre two floors down, for a cup of tea and a debrief on events with some like-minded colleagues.
I decided to speak to the Supervisor of Midwives on call, who happened to be one of my managers and also a friend, to let her know what was happening in case I needed some support later. However, my heart sank when she started the call with the words "Oh Mia, I'm so glad you called! I heard that you had a breech on the labour ward and that you were planning to deliver it!" She sounded as alarmed as though she had just heard I was about to do a caesarean at home, on the kitchen table, using a butter knife. "Yes, it's going to be fun!" I replied, trying to inject some humour into the situation. "Oh but Mia you have no experience and it's really not safe for you to do this and you have to think of the woman and." She continued in this vein for some time, while I tried to get a word in edgeways: "But. it's just that.. will you listen.?" Eventually, when I managed to tell her that one of the consultants would be in the room with me, she said "Oh thank God!" Well, thanks for the vote of confidence.
I began to realise that I was on my own here. The consultant was slowly turning into the control-freak from hell, the Supervisor on call seemed to think I was a liability, the labour ward co-ordinator on that night just happened to be someone with whom I had had a fairly explosive run-in only a few weeks previously, and my own Supervisor, whom I love dearly and who would have been the perfect support, wasn't on call and anyway had a prior engagement that evening. I wasn't worried about the birth - I genuinely believed that Fay could birth this baby beautifully - but I was terrified at the thought of trying to assist her in the midst of a battle for control. I just couldn't see how I could win.
A few minutes later, Karen called and told me that Fay was beginning to push. I ran back up and was immediately cornered by the consultant, who wanted to talk to me about the 'delivery'. She had decided that, as she was more used to breeches in lithotomy, this was the method she wished to employ. Inwardly I sighed - deep down I had known it would come to this. My final chance to claw this back was if Fay said no, so I said that I would talk to her. The consultant said ,"Yes, let's talk to her", and marched in to the room ahead of me. She approached the now-involuntarily-pushing woman and said "Now I know there are lots of position that you can deliver your baby and that you have discussed them with your midwife, but I'm much more used to doing it with your legs in stirrups so I'd like to do it that way - that okay with you?" Unsurprisingly, given her extreme vulnerability at that stage of her labour, Fay nodded her consent and the battle was lost.
We watched as, spontaneously, Fay began to bring her baby down the birth canal, which seemed to stretch perfectly well, thank you very much - penetrative intercourse or no. On three occasions the consultant knocked and entered (without waiting to be asked, naturally) but left us alone when she realised the birth was not yet imminent. We helped Fay on to the birth stool to bring the buttocks down, which worked well. Eventually, as the buttocks began to distend the perineum, the by-now-inevitable circus began. Lithotomy poles were put in place at the consultant's request. One of the labour ward midwives waltzed in uninvited. I was just too focused on what was happening with Fay to fight it all at that stage. I looked on as the consultant descended with a pair of episiotomy scissors (to be fair, as a previous FGM it may have been my choice also) before taking my place between Fay's outstretched legs.
'Delivery' has never been a word I've been comfortable with; I simply cannot bring myself to describe any birth I've attended as 'my delivery' because I strongly feel it implies that I'm doing the work, something I find insulting for the woman who is birthing her baby. This experience, however, was undoubtedly a delivery. As the buttocks and trunk descended beautifully, I watched and sat, albeit metaphorically, on my hands. The consultant, despite her previous assertions at Mary's wise words, urged me to "flex the knees and deliver the legs". When I replied that they were coming of their own accord, she reached over me and pulled them out herself. The right arm was born spontaneously; the left was clearly on its way. Once again, she leaned over me and tugged on it, to bring it out. I was beside myself with rage but felt completely powerless to stop her, judging that indulging in fisticuffs over the perineum might be counter-productive, however tempting. I supported the body and waited for the nape of the neck to appear, before bringing the baby up using the Mauriceau-Smellie-Veit manoeuvre, the exact movement that would have happened automatically had she been allowed to birth on all fours. The head was not yet ready to come so, after feeling the heart rate beating reassuringly fast under my hand, I waited for a moment more. Over my shoulder I heard a clink and saw the consultant approaching with a set of forceps in hand. "Push!" Karen and I desperately implored, and without any further ado, the baby was born, with Apgars of 8 and 10.
Word spread quickly around the hospital about our unusual event. The next day when I came in to see Fay, cries of "Congratulations!" "Well done!" rang out wherever I went, and Fay herself could not have been more delighted with her baby and proud that she had done it all without a caesarean. But, away from Fay, I could not bring myself to feel proud or triumphant about our 'achievement'. Instead I felt we had been cheated. Fay had been cheated out of the birth she had wanted, even if she did not - or chose not - to realise it. I also felt cheated: my first breech should have been a moment of wonder and exultation. I felt wildly angry about the underhand tactics used by the doctors. I felt the whole day had been an exercise in power, manipulation and control by the medical team and that they had laughed at us behind our backs for our foolishness in thinking we might be the ones controlling the situation. Most of all, I felt so thoroughly ashamed of myself. Ashamed for the compromises we made, ashamed for losing the ability to advocate for my woman, ashamed for being unable to defend Fay from the medical onslaught to which we had been subjected.
I try to look at the positives: she had the midwife she wanted at the birth, she birthed vaginally, both she and her baby were healthy. More than one colleague told me that I should be happy even for the 'small steps'. But for me, small steps are not enough. Only a giant leap will be good enough for each woman.
In two months' time I have a woman who wants a waterbirth with her twins. Wish me luck.
This article was originally published in Midwifery Matters ISSUE 114, Autumn 2007
AH updated 30 January 2009