I started my time as a specialist obstetrician a few months after the Term Breech Trial was published (Hannah, et al., 2000). I made a determined effort during my training to acquire the knowledge and practical skills I needed to support women during their vaginal breech birth and have actively maintained those in the years since (mostly through teaching and simulation practice). It wasn’t always easy and at times I have been criticised by my peers for persisting. A phrase I have heard more often than I care to over the past 20 years has been some version of “I (or we) don’t do vaginal breech birth”.
Let’s look at what is going on in that statement and see why I think it is morally reprehensible for an individual practitioner or maternity service who provides intrapartum care to say this.
When you are pregnant you don’t get always get a choice about whether you get to “do vaginal breech birth”. You have no control over whether or not your baby will turn head down before labour starts. You have no say in when or where your labour starts, or in how quickly it progresses. As a consequence, each year a number of people will find themselves in need of a practitioner who can competently support them when it is simply too late or just plain inappropriate to do anything other than give birth to their baby vaginally.
When a practitioner, or an entire maternity service even, makes the statement “we don’t do vaginal breech birth”, what they are really saying is that at some point they decided to not invest in developing a set of skills required by a competent clinician who provides intrapartum care. Because birthing women can’t opt out of vaginal breech birth 100% of the time, neither can clinicians. “I don’t do vaginal breech birth” is equivalent to saying, “evidence shows you are likely to have a better outcome if I had learned and practiced this skill, but that would take me outside my comfort zone, and so I decided instead that I felt that it was OK for you to face the consequences of my lack of skill”. Ethical care provision doesn’t look like that.
Some pregnant women will weigh up their options and make a decision that vaginal breech birth is right for them. “I don’t do vaginal breech birth” is equivalent to saying, “I don’t consider your decision to be valid, so I am going to back you into a corner where your options are to agree to a caesarean birth or give birth without a skilled attendant. And oh, by the way, if you pick the second option and something goes badly, it’ll be your fault, not mine.” Woman-centred care isn’t picking the women that you agree with and ignoring the rest.
Intrapartum care provision is by nature unpredictable, it’s not a menu you get to pick and choose from. “I don’t do vaginal breech birth” is equivalent to saying, “I don’t do caesarean section” or “I don’t do shoulder dystocia”. You either commit to having the most comprehensive skill set you can, to provide the best care you can, or you get out of the birth room.
If you are a practitioner providing intrapartum care, or manage a service which provides intrapartum care, and you want to do better, there are options. Dr Shawn Walker’s research into physiological breech birth is revolutionary. Go look it up and read it. Particularly this one. If you are in the UK, attend one of her courses. If not, visit her website and look for her videos on Vimeo and Youtube. In Australia, go to a Become a Breech Expert (BABE) course. Set up a local network of interested practitioners and educate yourselves and others and practice simulations regularly. If you known of other local options, post a comment below so that others can find them too.
Know better, do better, be better.
This post was prompted by reading this newly published commentary, which is freely available: Leeman, L. (2020). State of the breech in 2020: Guidelines support maternal choice, but skills are lost. Birth. doi:10.1111/birt.12487
Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R., & Term Breech Trial Collaborative Group. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356(9239), 1375-1383. https://doi.org/10.1016/S0140-6736(00)02840-3