Critical approach to medical advice is best for mothers: Midwives play key role

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I was invited to write this editorial after speaking about my decision to birth my baby vaginally despite her breech position. While my choice ran contrary to dominant medical opinion, it was right for me and my baby. Not only was she born healthy, but I was well, satisfied that I had given my baby the best possible start to life. I was empowered by my involvement in the planning. Here is my story which demonstrates that in order to ensure the best birthing outcome women need to take a critical view of medical advice. I believe it is the role of the midwife to encourage and support women in taking responsibility for their own decision making, health and preparation for birth.

When I was eight weeks pregnant I met with an obstetrician. Let's call him Dr. Fisher.¹ One of the first things he did was look me over and ask if I’d had an eating disorder. This surprised me. I am of modest build but not underweight and I’d always enjoyed plenty of food. Dr. Fisher gave me an internal exam and said he doubted I would be able to have a natural birth. A C-section would probably be necessary.

We were disappointed. We had hoped for a natural birth. So the next day my husband Jon called an acquaintance, who is an experienced midwife, for further advice. She said it was unlikely my pelvis would be too small for a vaginal birth and it was difficult to tell without a trial of labour. I now understand that not only do women usually have babies appropriate to their own size, but the pelvis opens up during childbirth to allow the baby to pass through. The midwife suggested we think about going through the birthing centre at one of Sydney's public hospitals near our house.

At the birthing centre were midwives who championed the use of natural pain management such as warm baths and upright positions. We booked in and were designated a midwife – who I’ll call Jenny – who would care for us through the pregnancy and birth. During long appointments she gave in-depth explanations of our options for medical care along with emotional and practical support. We came to know and trust her. Just in case we needed that C-section after all, we also privately employed a senior obstetrician at the hospital—let us call him Dr. Gardner. If complications arose during the labour and I had to have surgery, I’d prefer to know the doctor.

I built on existing relaxation and meditation skills with a CalmBirth course. I swam, walked and did yoga. I employed a doula to provide support in non-medical areas, such as massage and liaison with the medical team, particularly if Jenny couldn’t be at the birth for some unforeseen reason.

I felt happy with this arrangement but my encounter with Dr. Fisher had taught me that at best, opinions and approaches differed widely among medical practitioners, and at worst, some advice could be wrong. Questioning and critical thinking were necessary to find the best outcome for myself and my baby.

During the third trimester my baby seemed stuck in breech position. Dr. Gardner said I needed an external cephalic version (ECV) and if that failed, a C-section. When later that day I asked Jenny if it was normal to do a C-section for breech babies, she told me about the Term Breech Trial that had found an increased risk with a vaginal birth compared to C-section. She said there were question marks over the trial and suggested I look into it. Few obstetricians were still doing vaginal breech deliveries, but Dr. Gardner – who had publicly expressed concerns over Australia's high C-section rate – was more likely than most to do a vaginal birth if I asked, she added.

Three weeks before my due date the ECV failed. Dr. Gardner recommended a C-section. I asked why vaginal delivery wasn’t recommended for a breech baby and he referred to the Term Breech Trial. I was disappointed. After all we’d done to get this far toward natural birth, we’d suddenly come back to a C-section.

I was wary of a C-section partly because of my mother's experience. I was born via C-section 35 years ago and she found the recovery long and painful. I felt that such pain and associated pain killers would make it difficult to maintain a positive frame of mind and to give my baby the love and attention I wanted. I also thought getting sewn up on an operating table wasn’t ideal for initial bonding and breast-feeding, and I understood there were risks associated with C-sections, of infection, bleeding, clotting and uterine scarring for the mother, and breathing problems and premature birth for the baby.

To be sure, the Term Breech Trial found a small but statistically significant increase in the risk of short-term serious morbidity for breech babies born vaginally versus by C-section. However, I knew that there had been many questions about the trial's methodology. All the doctors had skills in performing C-sections but many of the doctors lacked experience and skill in vaginal breech birth; this was not acknowledged as a factor that could possibly explain the poorer birth outcomes for vaginal breech births. Also there have been criticisms of the authors’ interpretation of their results. It seemed significant to me that a follow-up of half the babies in the study two years later found no significant difference between the babies where the mother planned a vaginal breech delivery and where she planned a C-section. When I put my concerns to Dr. Gardner, he agreed there was debate about the trial. Jon and I went home to a weekend of agonising over what to do.

My starting point was that I wouldn’t put my baby at risk for anything: her safety was paramount. Yet the Term Breech Trial's coverage of 2088 women from 121 centres in 26 countries offered a broad generalisation. It didn’t account for my individual circumstances. I’m not a statistic. There were special factors about me that could have some influence on the outcome. I wondered whether the women who chose to partake in a trial where they were randomly assigned to C-section or vaginal birth would bring the same determination and resources to pregnancy and birth as I had. I felt that the calm breathing and relaxation techniques I had learnt could contribute to my labour progressing well by avoiding the fear-tension-pain cycle that could slow down the birthing process or create the need for pain relieving drugs that could do the same. Were the women in the breech trial taking advantage of gravity or were they laying on their backs while they laboured? Were they as physically fit as me? We decided we had more questions for our obstetrician.

When asked, Dr. Gardner said he didn’t think vaginal breech delivery was more risky if certain parameters were in place – i.e., the labour was progressing, the baby wasn’t feet first – but fear of litigation after the Term Breech Trial had caused widespread aversion to vaginal breech delivery among obstetricians. He had done successful vaginal breech deliveries – although not for some years – and would do one for me if I wanted. I was relieved but there was a catch. He didn’t work every weekend and if one of his partners was filling in, they would do a C-section. It would be a shame to have major abdominal surgery because my doctor was off duty, but it appeared we had little choice: that is until my doula mentioned Dr. Andrew Bisits in Newcastle who had a reputation of supporting women to have vaginal breech births.

When we met Dr. Bisits he explained it is safe to have a breech baby vaginally within certain parameters, including that the baby isn’t too big, that the type of breech presentation is favourable, that the labour can be monitored carefully, that there is room in the mother's pelvis and that a skilled obstetrician can be at the birth. At the John Hunter, his team has done about 400 planned vaginal breech deliveries using this formula. Of these, there was one case of serious birth related morbidity – an initial lack of oxygen – but the baby recovered within about an hour, is developmentally fine and now attending school. He said it is important for the mother to be well informed and feel confident. He mentioned two women who had travelled from Townsville to have breech babies under his care the previous week, and he stressed how determined and strong they were. “Sometimes you’ve just got to make it happen and that's what these women did,” he said. Dr. Bisits said he would switch to a C-section if the labour wasn’t progressing. He’d give me about 12h, and the pace of the contractions and cervical dilation would need to be consistent. We decided we wanted a vaginal breech birth and we wanted Dr. Bisits to be our obstetrician.

I was 40 weeks pregnant when my waters broke, I went to the hospital for observation. Early the next morning my labour began with frequent intense contractions and I became focused on relaxing my muscles and doing my breathing and visualisations. Anything that disrupted my concentration increased my experience of pain and made it less tolerable. A warm shower provided some relief and I stood for all of the first stage as the pain seemed much more manageable in this position. I felt reassured by the presence of midwife Mandy Hunter. When Dr. Bisits had introduced me to Mandy previously, I’d been impressed with her knowledge and gentle yet forthright manner. She’d had experience with breech births, including alongside Dr. Bisits, and she seemed supportive of and in sync with the doctor and his program, which encouraged my hopes for a harmonious birthing team. Mandy had also been supportive of my wishes and simultaneously practical. She went through my birth plan, telling me what was possible and what might be unwise or unavailable in certain circumstances. One of the requests in my birth plan was that I not be offered any pain relieving medication, and throughout the labour, I didn’t think about drugs.

I laboured well and quickly; Mandy moved me to a birth stool for the pushing phase so Dr. Bisits could closely monitor the birth. When my contractions and urge to push eased, Dr. Bisits explained how to think about pushing so I could harness the correct muscles. He said I shouldn’t rely on contractions to get the baby out. “Remember what I told you before, sometimes you’ve just got to make it happen.” I employed every bit of mental focus and physical strength I could muster and pushed my baby out. It felt like one of the hardest things I’ve done, and the most important. I doubt I would have been so focused throughout the birth had I not been informed and involved in planning the birth.

The labour was eight hours. There were no complications, not even a tear. Lucinda was well. Drug free and skin-to-skin, she fed well and we went home later that day. When I look back at the experience, it gives me confidence in my ability to make important decisions, which has been helpful in child rearing where there seems to be a plethora of views on every topic.

The record of the John Hunter convinced me vaginal breech delivery can be safe in a unit where it is common practice, where doctors and midwives have the appropriate skills, and strict criteria are met before and during the labour. If one man and his team can provide this service within the public system, why can’t all women be given this option?

In conclusion, it is important for pregnant women to take responsibility for their health and care while considering advice. Not only can medical advice differ widely between obstetricians and be impacted by ideology as well as practicalities like fear of litigation, there are factors for women making the right birthing choices that aren’t strictly medical, such as mother and child bonding. The woman herself – attributes such as her physical fitness, pre-existing skills, determination, confidence in her body and mind, and her trust in her birthing team – can be big factors in achieving a successful outcome. Midwives can play a key role in supporting a woman's independent decision making and helping her achieve her desired outcome by providing her with unbiased information and emotional support within a relationship of trust. Throughout my journey, the midwives I met along the way were pivotal. They showed me I had options and gave me enormous support in pursuing my path, without which I may not have had the courage to steer an unusual course.

• 1 I have changed the names of individuals where identifying them may have caused embarrassment for themselves or others.