In Ottawa, Canada, on a Friday morning in April, 2006, Robin Guy woke up, her membranes ruptured and she knew it was ‘time’. Today her second child would be born. They’d known for months that the baby was breech. She had been breech at the 20-week ultrasound and never turned over. Robin’s midwife was not experienced in vaginal breech deliveries. Having trained after the ‘Term Breech Trial,’ the single research project that had stopped vaginal breech deliveries cold in most developed countries around the world.

They had spent weeks searching for someone who would be willing to provide her with the care and support to deliver her baby vaginally. They had managed to find two practitioners within their region that would be willing to “catch the baby”. This was only if she went into labour while they were on call. She arrived at the hospital ready to push, and she refused the caesarean section that they would “have to” try to talk her into.

Today was not the day either of them would be on call. After many phone calls between Robin, her midwife and the nearby hospitals a decision was made that they would travel to Almonte, a small town outside Ottawa, as her midwife felt they would get more flexibility there.

After arriving at the rural hospital, it was determined that the obstetrician on call had also trained after the ‘Term Breech Trial’. She had experienced only twelve vaginal breech deliveries during her career. She was not at all confident or comfortable performing a vaginal breech birth. and “She told us point blank that she couldn’t offer anything other than ‘elective caesarean’. Here we were again, though, with that ‘elective’ word that was just not an option“, Robin recalls.

They waited, hoping labour would not establish until the following day when she knew there would be a practitioner on call that would be comfortable to “catch the baby”. However, the contractions started to come in the late afternoon, and they returned to the hospital. “We got to the hospital at 6pm and it was as if a switch turned on and suddenly I was in transition. The OB came into the room and actually sat down cross-legged on the floor so that she could talk to me at eye level, and went over the “risks of c-section” (as if I had a choice) and things I “should know.”

I had about 8 contractions over the next hour. At about 7pm we alerted our midwife that I was starting to feel pressure in back and that they had better check me. The OB came back in to check me and just kind of stopped dead. “Where are we at?”. “9 cm” she said. I had been in labour for 75 minutes – about ten contractions in total. All I had left was a lip. I swear she almost let me go.

Then she got scared again. I guess because all hell broke loose as they suddenly rushed to get me into the OR. They were paging people, had trouble finding the paediatrician, etc… I was pushing before they got me in there. The only reason Miriam didn’t just come out was because my midwife got right in front of my face and I could look into her eyes and breathe with her – not pushing was the hardest thing I could’ve imagined. And my body was still doing it. Once they had the spinal in it slowed my body down but only just enough for them.

I don’t think anybody in that room thought the right thing was happening. “Somebody is PUSHING” the anaesthetist said… I think she was trying to give the OB an excuse to stop.” “Nobody believed that it had been right – only that it had been the only choice, because the obstetrician had never had the opportunity to get good enough at breech delivery to do it “safely.” Realistically, I would’ve had that little baby out in about three pushes and nothing would’ve gone wrong and everybody knew it. The OB came to talk to me before she went home, and said as much herself. “This doesn’t feel right,” she said.”

Eight months after the caesarean birth of her daughter Miriam, sitting under a tree in a snowy park, Robin co-founded the Coalition for Breech Birth (CBB). Robin recalls “the three women under a tree were myself, Michele Schubert and Jennifer Stewart. I met them through our local midwifery consumers group. I joined the group shortly after Miriam’s birth. The girl who ran the email list heard my story and said “hmmmm, you need to connect with Jen Stewart, that happened to her too, and she is as mad as you are.” Jen knew Michele, whose baby was born vertex but had been breech very late in her pregnancy, late enough to lose those last precious weeks of pregnancy to the breech worry.”

The CBB is a consumer driven organisation advocating for the re-normalisation of vaginal breech birth. They provide information, networking and support to women and their families. Especially as they prepare for the birth of their breech babies. They facilitate training and networking opportunities for care providers who wish to support informed choice in breech birth. Now beyond Canada, the CBB has sister chapters in the United States, United Kingdom and Australia.

“Our initial goal was to get information out – the website was the very first thing we did. I wrote most of the content and Jen designed and created the site. We also posted an online petition, delivered to the Society of Obstetricians and Gynaecologists of Canada (SOGC), petitioning for a change in the breech guidelines.” The petition was submitted in July of 2008, and in June 2009 the SOGC released the new guidelines which encourage the practice of vaginal breech birth[1]. Initiatives to restore vaginal breech teaching to Canadian medical schools are now underway and Canadian women are starting to see a slow increase in the number of “breech catchers” available.

The CBB’s achievements don’t stop there, having hosted the second International Breech Birth conference in October, 2009 in Ottawa, Canada. Currently, CBB is in preparations for the Third International Breech Birth Conference. They will hold it in Washington DC on the 9th – 11th November, 2012. These large conferences have, in the past, provided an opportunity to get consumers, midwives and obstetricians together, from around the world, with various levels of experience and understanding of vaginal breech birth.

This gets them all together in one room. It gets them to discuss this complex phenomenon from multiple perspectives and what changes can be made to improve the outcomes for mothers and babies. The guest list for the third International Breech birth conference already includes Dr Frank Loewen, who will discuss his work in Germany which encourages the hands-and-knees delivery position; midwife Betty-Anne Daviss; Dr Stuart Fischbein and Dr Michael Hall from the USA and other guests who have not yet been confirmed, including specialists from Australia.

Many Australian hospital policies and obstetric practices still recommend elective caesarean section for all breech babies. This is despite peer-reviewed research since the ‘Term Breech Trial’ that does not support this practice. This includes the TBT’s own two year follow up, which negates the original conclusions by stating that at two years old, there is no significant difference between the health outcomes of the children in the vaginal birth and caesarean birth groups [2-7]. Significant policy changes in countries such as Canada have paved the way for countries such as Australia to take notice and provide options beyond a caesarean section for all breech presentations. Personally, I know full well the stress and worry when carrying a breech baby. Not because my baby was breech, but the need for that desperate search to find a practitioner to care for me, in a way other than an automatic caesarean section.

One woman who knows and understands the breech dilemma is documentary film maker Karin Ecker, writer, producer and star of “A Breech in the System” [8]. In her documentary, Karin shares her journey through the stress related to carrying a breech baby; the struggle to find a practitioner to provide her with safe care; undergoing an ECV; and booking an elective caesarean section, only to change her mind on the day surgery was booked. Her initial intention had been to film her son’s birth, so that he could one day look at his own birth and it unexpectedly turned into a documented account of her breech journey. Karin recalls, “The idea to make a film only came two year later as I wanted to make a film for the ABC on birth”.

Melbourne lawyer and mother, Rhonda Tombros was planning a birth at the public hospital with the midwives, in March, 2011. As she had only recently moved to Australia and was unemployed, she had spent a lot of time reading about birth. She was aware of the controversies surrounding breech birth. “We realised the baby was breech at about 30 weeks and this was confirmed at a routine check-up at 36 weeks. After attempting a variety of non-medical attempts to turn the baby, we attempted ECV at 37 weeks but the procedure failed. I had mixed views about it. Although I recognise that this is many women’s best way to avoid a caesarean, it still felt wrong to interfere with my baby’s naturally assumed position.

My husband felt the same way and even considered asking the doctors to stop midway. I then had a meeting with the doctor and told her that I did not want a caesarean. She said that they could not force me but that I should discuss it with her supervising consultant, whom we met at 38 weeks.

The consultant explained that whilst she and several other doctors were experienced in vaginal breech birth, most doctors at that hospital were not supportive of it. and in her view, my best chances of a vaginal birth would be to be induced so that I would be ‘in labour’ when she was on duty to deliver the baby. We consented but later regretted it as we believed that spontaneous labour would maximise our chances of a successful vaginal birth. We could not see any medical reason for an induction, which would almost certainly lead to a traumatic time and eventually a caesarean.”

Rhonda’s husband, Michael, a Melbourne GP, called around to his medical colleagues. Rhonda continued a desperate search on the internet. Between them, they were able to find three private obstetricians in Melbourne. These obstetricians may support her to try a vaginal breech birth, to then find only one that was available at such short notice.

Forced to borrow close to $10 000 to have the opportunity to attempt a vaginal breech birth. Rhonda describes herself as being “extremely lucky” to be able to borrow the money and that “my bodily and psychological integrity was worth more to me and my husband than the debt. Although I resent the fact that I had to pay to avoid surgery (and therefore missed out on all the great services and facilities offered at the public hospital), I am glad this option was available to me and very grateful that I have a husband who would support me in this way.”

Rhonda’s baby Matilda, was born at 41 weeks and 3 days gestation and narrowly escaped the ‘42 week caesarean deadline’ she was facing. “My labour was about 7 hours and the birth unproblematic. It was a vaginal breech ‘delivery’, in that the doctor very gently helped with the legs and arms and controlled the descent of the head. I still can’t understand why they prevented so many women from even trying. It makes me really sad.”

After the birth, Rhonda was surprised to find she still felt traumatised. She carried a lot of “baggage” due to how her situation was dealt with by the Australian medical system. Rhonda and Michael then decided to start a support group for Australian women who had beech babies (vaginally or surgically) for three reasons:

1. The stress she experienced before and after the birth of her breech baby, despite achieving a strongly desired vaginal breech birth.
2. To build a resource for resource for pregnant women with breech babies so that they could find all the information they need in one place (ideally a website)
3. Those who want to campaign for changes to the treatment of breech in Australia would have more influence together and could also share information. Rhonda and Michael decided to start with Facebook, initiating a support group titled “Breech Birth Australia”.

This lead to the discovery of Robin Guy’s ‘Coalition for Breech Birth’. Rhonda explains, “It is amazing how empowering the knowledge, that other people have been through the same experience can be, when you feel like you are the only one challenging the system.” Rhonda is now heading the Australian Chapter of the CBB. She is working on moving Australia forward on the issue of vaginal breech birth.

Robin, Karin and Rhonda’s stories are all too familiar to me. Having also walked the breech journey with my second pregnancy in 2009. I was fortunate enough to find my obstetric ‘angel’. Fortunate to get my vaginal breech birth, but not without a lot of unnecessary heartache along the way. It is not a path I would wish for my sisters or daughters to follow. I only hope that Australian hospitals and practitioners can learn from countries like Canada. Also for them to listen to the women who are asking for more.

Robin’s journal entry from Miriam’s nine-month birthday reads: “My heart still aches every day. Every day my brain plays out a new scenario in which I deliver my baby. In which I leave and deliver in the parking lot; in which I DO push. Slowly it is coming to hurt a little less, but it’s been a long road. It was my body. My baby. It should have been my choice, and I felt and feel utterly violated. This must not happen to my sister. This must not happen to my friends. Most importantly, this must not happen to my daughter.”

Article written by Danielle Freeth

Further information

For more information please visit www.breechbirth.ca or contact info@breechbirth.ca

Robin’s full story, “Birth of Miriam Hannah: Forced Breech Caesarean” can be read at the Coalition for Breech Birth website: www.breechbirth.ca

Rhonda’s full birth story appears on Breech Birth Australia and New Zealand Facebook group.

Women can be referred to Rhonda and Michael’s consumer support group via, http://www.facebook.com/groups/breech/ or email CBB_Australia@breechbirth.ca or alternatively the CBB’s international consumer support page at http://www.facebook.com/groups/5701718161/

Karin’s ‘A Breech in the System’ documentary can purchased in the Pregnancy Birth & Beyond Online Store

References

1. Kotaska, A., S. Menticoglou, and R. Gagnon, Vaginal delivery of breech presentation. 2009, Society of Obstetricians and Gynaecologists of Canada (SOGC): http://www.sogc.org/guidelines/documents/gui226CPG0906.pdf.
2. Hannah, M.E., et al., Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet, 2000. 356: p. 1375-83.
3. Hannah, M.E., et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term.  The international randomized Term Breech Trial. . American Journal of Obstetrics & Gynecology., 2004. 19(3): p. 917-27.
4. Whyte, H., et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term. The International Randomized Term Breech Trial. American Journal of Obstetrics & Gynecology., 2004. 191(3): p. 864-71.
5. Goffinet, F., et al., Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American journal of obstetrics and gynecology, 2006. 194(4): p. 1002-11.
6. Glezerman, M., Five years to the term breech trial: the rise and fall of a randomized contolled trial. American Journal of Obstetrics & Gynecology., 2006. 194(1): p. 20-5.
7. Uotila, J., R. Tuimala, and P. Kirkinen, Good perinatal outcome in selective vaginal breech delivery at term. Acta obstetricia et gynecologica Scandinavica, 2005. 84(6): p. 578-83.
8. Ecker, K., A Breech in the System. 2009: Australia. p. 43 minutes.