Archive for June, 2009|Monthly archive page

More On Breech Birth . . . Could There Be Change Afoot?

For those of us keeping an eye on what is happening with breech birth these days, there are hopeful signs that vaginal breech birth may become a more accessible option once again.  We blogged about the new guidelines put forth by the SOGC (the Society of Obstetricians and Gynaecologists of Canada) last week, but wanted to follow up.  We hope that ACOG is paying attention to what their colleagues to the north are saying and doing.

 Please read the SOGC guidelines, as well as the commentary from Dr. Andrew Kotaska.  The guidelines state that “planned vaginal delivery is reasonable in selected women with a term singleton breech fetus”.  Dr. Kotaska, one of the authors of the guidelines, points out in his commentary that over 100,000 women have babies that are breech at term, and that with reasonable and conservative practice guidelines, over 25,000 of these women (and babies!) could avoid cesarean and have their babies vaginally instead.  WOW!  And imagine up to 25,000 women that wouldn’t have to navigate the politics of a VBAC.

In case you think this estimate is being pulled out of a hat . . . check the PREMODA study, which trumps the (in)famous Term Breech Trial study.  You can read the abstract and summary of the PREMODA study here.   The Term Breech Trial has been widely criticized for major study design flaws and conclusions, though it was at one time considered the definitive study on cesarean vs. vaginal breech birth. Lots to look up on this one.

Below is a letter from  Robin Guy, co-founder of the Coalition for Breech Birth in response to the new guidelines issued in Canada last week:

Dear friends of CBB –

Well, here we are. Women’s voices are finally getting heard – the Society of Obstetricians and Gynaecologists of Canada has issued new breech guidelines that above all, advise that women need to be offered the choice of vaginal breech birth. What is the most important about these guidelines is not the nitty-gritty of candidate selection and techniques of delivery, but rather that they have tackled the ethical issue of forced surgery and come down firmly on the side of not obliging women to have surgery they neither want nor need.

Link to the new guidelines and commentaries (please especially read Andrew Kotaska’s commentary) – http://www.sogc.org/media/advisories-20090617a_e.asp

For those of you not in Canada, this is a great opportunity to approach your own organizations and present this example of progressive movement towards recognizing women’s autonomy over their own bodies and ownership of their birthing.

So one battle is won, but the next is beginning. The guideline change will offer those doctors and midwives who were willing to catch, but afraid of professional censure or litigation, the excuse they need to start catching openly and helping to train their colleagues. The SOGC is also launching training initiatives that will help the care providers currently in school to gain these skills and graduate competent to include vaginal breech in their practice.

However, as always, the real change must come from us. The real change must come from women and their families expecting better care. Expecting to be offered unbaised informed choice discussions and for our choices to be respected and supported. Expect referrals to competent attendants when our own midwife or doctor legitimately doesn’t have enough experience to safely catch our breech babies.

Please. Tell your friends what has happened. Shout it to the rafters. Watch for the Conference registration announcement (it will be October 15-16, in Ottawa), and do whatever you can do to be here.

Let’s make some noise.

blessings,
Robin


Learn. Educate. Speak out. http://www.breechbirth.ca

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“Denying vaginal breech birth is a human rights violation in that it forces a woman to consent to surgery in order to obtain medical care. The right to informed consent is meaningless where there is no right to informed refusal.”

 – Henci Goer, author of “The Thinking Woman’s Guide to a Better Birth”

Please contact Christie Craigie-Carter, at International Cesarean Awareness Network (ICAN) for more information about what ICAN and other organizations are doing at the national level to draw attention to this issue and effect change. You as a consumer can make change happen too!  Christie, incidentally, had two breech babies by cesarean before having her third breech baby vaginally at home. 

And lastly for some inspiration and a reminder that breech is a variation of normal . . .here is an amazing photo sequence of a footling breech homebirth in England.  Check it out!

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Think About Keeping Your Pants On!

I read a great blog post today by a Certified Nurse Midwife about the usefulness (or actually, the possible emotional harm!) of vaginal exams prior to the beginning of labor. I think this is a great read and good information to take to heart, especially for those women who are having a VBAC.

The question I always ask is this…. ‘Will the information gained from THIS vaginal exam change what we are going to do today?’ In your present situation, unless you are considering being induced a vaginal exam is irrelevant. What do I mean irrelevant…it does not change what we are going to do TODAY and things can literally change overnight. Because of this, I encourage you to avoid all vaginal exams until you think you are in labor and are having a labor check or you are preparing for an induction.

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Head over to this blog and read the entire article! At your next appointment, think about keeping your pants on! Skip This Routine!

Oh Canada! Breech Birth Preferred over Cesarean for our Neighbors to the North!

The Society of Obstetricians and Gynecologists of Canada (Canadian version of ACOG) has released a statement in response to new evidence that breech births can occur safely and may be the preferred method of birth over an automatic surgical birth for babies who are breech!  Some key points:

“The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth – spontaneous labour, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.
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“The safest way to deliver has always been the natural way,” said Dr. Lalonde.

“Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”

Here is the article in it’s entirety:  C-section not best option for breech birth

One of the challenges will be to find providers who have experience with breech births, as this art has been lost over the years, and the experience and training has been not handed down to the current providers catching babies!  Maybe time to call in some old midwives!

Maybe ACOG and the US will not be far behind, but until then, a current passport might not be a bad thing to throw in the birth bag!

The Latest Thoughtful “Work” from the AMA . . . .

AMA Resolution Would Seek to Label “Ungrateful” Patients

Redondo Beach, CA, June 11, 2009 – At the American Medical Association’s (AMA) Annual Meeting next week, delegates will vote on a resolution which proposes to develop CPT (billing) codes to identify and label “non-compliant” patients (1)

The resolution complains:

“The stress of dealing with ungrateful patients is adding to the stress of physicians leading to decreased physician satisfaction.”

“This resolution is alarming in its arrogance and its failure to recognize, or even pay lip service to, patient autonomy,” said Desirre Andrews, the newly elected president of the International Cesarean Awareness Network (ICAN).

If approved, the resolution could hold implications for women receiving maternity care. For pregnant women seeking quality care and good outcomes, “non-compliance” is often their only alternative to accepting sub-standard care. Physicians routinely order interventions like induction, episiotomy, or cesarean section unnecessarily.

Liz Dutzy, a mother from Olathe, Kansas, delivered her first two babies by cesarean and was told by her obstetrician that she needed another surgical delivery. “My doctor told me that I needed to have a cesarean delivery at 39 weeks, or my uterus would rupture and my baby would die.” She sought out another care provider and had a healthy and safe intervention-free {home} birth at 41 weeks and 3 days gestation.

A recent report by Childbirth Connection and The Milbank Memorial Fund, called “Evidence-Based Maternity Care: What It Is and What It Can Achieve ,” (2) shows that the state of maternity care in the U.S. is worrisome, driven largely by a failure of care providers to heed evidence-based care practices. For most women in the U.S., care practices that have been proven to make childbirth easier and safer are underused, and interventions that may increase risks to mothers and babies are routinely overused. The authors of the report point to the “perinatal paradox” of doing more, but accomplishing less.

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The resolution proposed by the Michigan delegation of the AMA could threaten patient care and patient autonomy for several reasons:

• Billing codes that would categorize any disagreement and exercise of autonomy on the part of the patient as “non-compliance” “abuse” or “hostility” could create a pathway for insurance companies to deny coverage to patients
• Use of these labels fails to recognize patients as competent partners with physicians in their own care
• Tagging patients as “non-compliant” fails to recognize that there is not a “one size fits all” approach to care, that different opinions among physicians abound, and that patients are entitled to these very same differences of opinion
• Labeling patients as “non-compliant” may, in fact, be punitive, jeopardizing a patient’s ability to seek out other care providers

The resolution also fails to address how it would implicate patients navigating controversial issues in medical care, like vaginal birth after cesarean (VBAC). While a substantive body of medical research demonstrates that VBAC is reasonably safe, if not safer, than repeat cesareans, most physicians and hospitals refuse to support VBAC. (3) The language in the resolution suggests that patients who assert their right to opt for VBAC could be tagged as non-compliant, even though their choice would be consistent with the medical research.

“The reality is that the balance of power in the physician-patient relationship is decidedly tipped towards physicians. The least patients should have is the right to disagree with their doctors and not be labeled a ‘naughty’ patient,” said Andrews.

About Cesareans: When a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies from cesareans include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. ICAN has 110 chapters in North America and Europe, which hold educational and support meetings for people interested in cesarean prevention and recovery.

(1) Resolution 710 “Identifying Abusive, Hostile or Non-Compliant Patients”

(2) Evidence-Based Maternity Care: What It Is and What It Can Achieve

(3) http://www.ican-online.org/ican-in-the-news/trouble-repeat-cesareans