My own musings on breech

I've had the pleasure of reading many of Rixa's thoughtful, eloquent, and evidence-based blog posts. The quotes you will see today are from this one.

Here I am, knowing all of these things and having reassured many other women about breech presentations, and I still can't stop fretting about the future: what if the baby stays breech? what would happen then? what would I do?...

Briefly, my birthing history in a nutshell is summarized by two cesareans for malpresentation and an incredible, life altering homebirth of my footling breech baby. The simple answer is to the question you pose above is that you would give birth to him/her. I suspect that you know that, but believe me I understand the battle between the logical mind and the emotional one. Believe it or not, it was my husband who was reminding me, frequently no less, of both the research regarding the safety of breech vaginal birth and how we had arrived at the decision to proceed with a homebirth in the event that baby also preferred breech. For even though my logical mind knew that there were risks no matter whether I had a cesarean or a breech vaginal birth, fear is a powerful thing.

It's not that I am worried about a vaginal breech birth per se. I feel quite confident that I could give birth to a breech baby, and I have read extensively about the controversies surrounding breech management. But I am quite afraid of birthing a breech baby in the current medical & legal climate.

In three sentences, you have summarized the crux of the crisis of breech birth.

She knows of a few physicians who, although they currently don't officially do vaginal breeches, might be able to attend a woman if she into labor on a day they happened to be on call and insisted on a vaginal birth at the hospital. She'd have to know that this option even existed and who to ask for, of course.

As a woman who was in a position very similar to this, I can tell you, and again I suspect you already know this, that this is not adequate. Case in point, the OB I saw in my second pregnancy, after again being "risked out of midwifery care", was skilled in breech. Yet, when I asked him to attend my breech vaginal birth, not only refused, albeit kindly, but chose not to inform me that his colleague across the street very well may have agreed to attend my birth. Quite simply, it's not okay. I've wrestled fairly well with my own demons, but I cannot give up this fight on behalf of other women faced with the woefully inadequate, and even dangerous “choices” that exist for breech birth.

A massive amount of stress and worry, because I could not simply carry on with my birth plans. Instead, the days or hours leading up to the birth would be characterized by extreme upheaval and uncertainty. And there's still no guarantee I could find someone willing to attend a vaginal birth.

Okay, remember how I said that I had wrestled with my demons? Well, your quote above brings me back to those raw emotions I experienced as I, rather than fighting the establishment that was neglecting to provide me options, fought myself and worse yet, my baby. I cannot forget how I struggled to forgive my child, because he did not turn vertex despite my concerted efforts to encourage him. Obviously I'm not proud of those feelings, but every time I am contacted by a woman who is being told that breech vaginal birth is not an option, and quite often told that it is categorically unsafe, I remember how I struggled with the difference between what my intuition told me, and the implication of the only “option” I was given (please see my post on the “Illusion of Choice”), though I realize now that I need to do a second post on the "Illusion of Choice" to address the reality that there often is no true choice presented.

The best possible atmosphere for a successful vaginal breech birth is one that is the least disturbed, one with low levels of stress and adrenaline, one with laid-back hands-off providers with lots of skill and experience seeing physiological breech births.

And I am thankful every day that I had exactly what you described. It transformed me in huge ways, and I am determined to help other women know this experience.

The problem with breech in this country isn't the actual presentation and birth--it's the hostile climate that makes a vaginal birth nigh to impossible.

I couldn't have said it better, and because I think she's reading, I must give a heartfelt thanks to L, who reminded me of as much when my emotions clouded my judgment.

Doing favors

A friend of mine recently told me that one of my midwives had told her "yeah, we did Christie a favor". I've spent a few days chewing on that, and of course, need to talk to the midwife before drawing any conclusions. Did she mean by agreeing to take me on as a client, by agreeing to proceed with a homebirth when he remained breech, or by not transferring due to the longer than anticipated labor. No matter her reply, I know that the word "favor" doesn't sit well with me at all.

I think what bothers me the most, is how indicative this is of the notion that women are not in the driver's seat for their births. It's ironic really, because I've often defended the thought that women can allow themselves to trust their care providers if they so desire. That doing so can be freeing. I think the concern for others is that in trusting a care provider, one can relinquish responsibility for the choices made. For me, trusting them was a recognition that I didn't have to know everything, and that there were some things of which I just needed to let go.

But I maintain that women are not done favors. No one cares about the well-being of their child more than a mother. Women, given the necessary information, are going to make the best decisions they can for the well-being of their family. These decisions are far from easy and very personal.

I get that midwives, and yes, even obstetricians often face dilemmas of which we are not even aware. But I continue to submit that if women are truly seen as partners in their care, many of the "what ifs" that providers fear, need not be feared. In the meantime, I'll keep chewing.

Being proud of being radical

Before anyone gets too worried, I'm not so delusional as to think that my birthing my breech baby at home is on the same scale as Barack Obama getting elected as President of the United States ;-).

But as I have heard person after person talk about how "historic" his election is, in addition to the incredible excitement I feel at the anticipation of his leadership, I felt uncomfortable with the focus on his race.

And that's where I see the parallel. Yes, technically speaking, it is most definitely noteworthy that he is to be our first black President. But what bothers me is that it is only because of our history, that it is noteworthy. It is nothing to be proud of that African Americans have not been given the same respect as European Americans; that our history is littered with shameful reminders of how we as Americans have mistreated our fellow human beings.

I remember how person after person told me how "brave" I was to give birth to my son at home. I was always uncomfortable with this adjective being assigned to my decision, my journey. For yes, there was courage involved; there always is when one surrenders to a process ultimately outside one's control. But underneath the word "brave", I couldn't help but wonder if they really meant was "reckless". And that I dismiss. For no one cared more about the well-being of my child than I, and no one examined the risks of the birth options available to me more than I.

Yet women are being persecuted for their choices around birth. And even the folks at Birth Trauma Association and Birth Trauma Canada think that women should be given the right to choose a non-medically indicated c/s due to previous birth trauma.

Talk about off the tracks. Let's not address ways to avoid birth trauma in the first place, or to help a woman overcome the effects of birth trauma before subsequent births; no, instead, let's "offer" her major abdominal surgery, which, in addition to the medical risks, involves an increased risk of trauma and depression regardless of it being a "choice".

And women have been harassed, threatened and even faced with separation from their babies simply for denying what they felt to be unnecessary treatment, often cesarean surgery. Look, what I'm going to say may seem offensive, but I promise that is not the intent; women who make informed choices about their births are not radicals, they are mothers. Until we start respecting a woman's autonomy in birthing decisions, women and families will continue to be harmed.

President-elect Obama's inaugaration theme is "A New Birth of Freedom". While women have many freedoms in our country, let's empower more and more of them to begin exercising their autonomy in birth choices.

Illusion of choice

So, as I've mentioned, I've become more brazen in my activism of late. Pretty much any pregnant woman or woman of childbearing age that I have a conversation with, I put on my education hat.

Today I approached two pregnant women in my son's gymnastic class. Both have had cesareans. I was surprised (only because I've never personally encountered the response) and very disappointed to hear that both of them were planning repeat cesareans, one because her hospital is banning VBACs (more on this later), and the other because she lives over an hour from the hospital and thinks it is just easier than risking having to endure labor and end up with a repeat cesarean anyway. They both say they are excited to know what day their baby will be born.

The resignation I heard from them both was so disturbing. I finally encountered the dichotomy; I work to help women who desperately want to avoid a repeat cesarean and here I am confronted with two women who choose to have one. And it is a choice in the sense that they are not being forced. The woman whose hospital is banning VBAC has at least 3 other choices in a 30 minute radius. She also admitted that she is looking forward to avoiding a long labor this time.

I've also heard many women over the years express relief when a reason is given to them for needing a repeat (breech, baby too big, etc.). They don't want to go through the process of labor, only to be disappointed again. Most will say it is a plus to avoid the pain of labor. But I wonder, if they aren't really hoping to avoid the emotional pain of feeling like they "failed" again. If they "choose" a repeat c/s, then they have autonomy and they have not failed. Is this perhaps what they think on whatever level of consciousness they are currently accessing?

The likelihood that either of these women has any knowledge of the risks of that decision is low. I'm pretty sure I've been discredited at this point in their minds; you know, I can't possibly understand, but I'm not giving up. I plan to bring them both a copy of "What Every Pregnant Woman Should Know About Cesarean Section" as well as "How to Plan a Family Centered Cesarean".

I feel strongly to truly make a choice, one has to be informed.

Certainty

Is anything ever certain? Are there guarantees? If we inform ourselves to the best of our ability, does that ensure that we will know all that we will need to know?

You know, I've gotten some strange looks when I've admitted that I don't trust anyone, even my husband, 100% with my children. The thing is, he's a phenomenal man and I trust him as much as I do any other human being. He's gentle, kind, loving, patient, understanding and even protective in his way. But I've seen far too many problems arise when people make an assessment, conclude that the person is trustworthy, and then turn a blind eye. I can't and I won't.

The guarantees part is harder for me. For while I know and accept that nothing is certain, I'm human and would like to think there are guarantees. If I do everything "right", will my desired outcome occur? And the answer is an ambiguous one--it may or it may not. The unknown variable here is chance. We can do all we can to ensure a desirable outcome, be it a healthy baby and mom, or "the right" decision, but in the end, there are aspects that we can never control.

There are many matters where certainty isn't required. We accept that there is no certainty when it comes to the weather, or even others' behavior. But when it comes to outcomes important to us, we want certainty.

I was intrigued to be instructed that we were not to seek certainty from the evidence in the recent trial case for which I was a juror. It makes sense now, but I had thought that the jurors "should" feel certain about their conclusions before deciding the fate of another. Now I understand how impossible and unfair this would be.

Having not been there and being unable to know for certain how credible a witness is, whether there was an attempt at deception or simply fuzzy memory about details not thought to be significant at the time, but which now take on great importance, there was more than a bit of faith involved on the part of the jurors.

In the end, we did the best with the information we had at the time. And that's all that we can ever ask of ourselves.

Jury Duty Part II: The decision making process

And what a process it was. It is an awesome responsibility to take a set of evidence, along with your own assessment of witness credibility, and sit in a room with 11 other people who have done the same. Everywhere we turned, there were fine lines. Words that most of us use in everyday language such as "intent", "display", "substantial", suddenly took on new significance.

A link to a newspaper article is here.

When choosing the jury, the prosecutor had used an example of fighting children in order to both illustrate and ascertain our own thinking about how to arrive at a conclusion about the sequence or even likelihood of the events. And I think about how in my own life, I make these assessments every day. It goes without saying that I will be doing so more carefully in the future, for although these decisions may not have the potential impact that today's assessment did, I have seen the value of weighing the evidence and coming to a conclusion.

Another layer of the human experience that surprised me somewhat was how bonded you can feel to others in such a short period of time. I've known my fellow jurors for all of 3 days, and yet the connection I feel to some of them far surpasses the duration of our relationship. Throughout this process, you really get to see who these people are. And what I saw were kind, compassionate, and caring people who wanted to be sure that the evidence was fairly evaluated.

After the trial concluded, the juror I had come to respect and care for very much, Maggie, and I asked to speak to the judge. We were both quite emotional, and told him how much respect we had for the process and how much more difficult it had been to make a decision with such great potential impact than we had anticipated. He was very gracious and empathic, even telling us that he and the attorneys had never been in our shoes and that he can only imagine the weight of the task for us.

He chuckled about how the detailed questions we kept asking annoyed him and impressed him at the same time. What was meant by display, did it mean that the victim had to have seen the evidence with her eyes or could she have heard it? If he had menaced her, had he also committed criminal intent?

Many times throughout the jury selection process and the deliberations, we were reminded (by the lawyers and the judge in the former case and ourselves in the latter), that we were not to consider the impact of our decisions on the parties. While I can certainly appreciate the reasoning behind this, it is exceedingly difficult to do. One elderly juror in particular continually raised questions to this effect. And we had to keep reminding him that it was not up to us to consider the impact of our decisions.

So here we are, wanting to consider the human beings that our decisions will affect, all the while it seems that obstetricians have successfully built a wall to prevent themselves from considering the impact of their actions on others. I don't think they are aware of this wall, nor that they intentionally built it, but nor do I negate its existence.

Similarly, I don't know that the defendant intended to injure the victim, but there was never any doubt in my mind as to the existence of injury to her.

Jury Duty and Maternity Care

Well, those of you who know me won't be surprised to know that I can often easily find parallels between birth and life. Here goes my description of that latest parallel. This week, for the first time, I was chosen to sit on a jury.

On Monday night, something I said jogged Andy's memory that I was supposed to call to see if I was expected to attend for jury duty. So, in a panic, worrying that I had been expected to be there on Monday, and having forgotten to call Sunday night, I dial the number. The recorded voice tells me that I was to report to the courthouse the next morning. I am both relieved (that there is no recorded voice telling me that I was in contempt of court for not going in Monday), and suddenly concerned about all the practical matters like arranging childcare for my 2 year old and 7 year old with whom I am homeschooling.

The next morning, I get up, convinced that if it is a criminal trial, I will not be chosen. As a social worker/therapist with an abuse history, it's a big stretch to find a case for which I can be truly impartial. Or so I think.

I can't get into the details of the alleged crime, but I think the process is decidedly more relevant. They revealed very few details of the case, just enough to ask the questions they needed to ask to pick a jury of his peers. I was not in the first group of jurors to go up and get questioned. In fact, with my crystal ball at lunch that day, I had calculated to my family that I had a less than 1% chance of getting on the jury, given that I had only calculated a handful of people that they would eliminate based on their responses to the questioning, and there were still greater than 30 of us sitting in the second group, each with only a 1/30 chance of being called to replace any eliminated jurors. I learned how inexact a science it is to calculate the actual likelihood of an occurrence. And no, it isn't lost on me that in the field of obstetrics, events with a 1% likelihood, or even less are often purported to have a much greater risk.

Upon returning from lunch, I learned that only 7 of the original 20 were chosen for the jury. So, another group of 20 was called up. As I often do :-D, while waiting during breaks in the process, I struck up a conversation with the woman sitting next to me. Being more brazen in my activism, and noting that she was a 20 something, I decided to take the opportunity to discuss ICAN's mission.

As it turns out, the young woman sitting next to me, though not pregnant and with no children, was very interested in hearing more. Her sister is pregnant, and having had a cesarean with her first child, is hoping to avoid one with this child. Yet, she's not feeling supported in that goal by her care providers, a tale all too familiar to those of us in the birth world. I shared with her some suggestions for how her sister might determine how supportive her doctors were of VBAC. I was able to suggest that there were other practices a bit further out of the area that might be more supportive of her wishes.

By the time she was excused from jury duty, I think there is a decent chance that either she or her sister will contact me for more information and/or come to a meeting.

Okay, back to jury duty. As I sat there listening to the process throughout the day, hearing the careful questions posed to potential jury members about their ability to be impartial and follow the mandates of the legal system; each time the question was posed to another potential juror, I considered it carefully. And despite my own history of family violence (this case does involve a level of violence), each time I mentally answered yes to the question of whether I felt I would be a suitable juror. One of the questions the judge posed to us to help us determine that was something to the effect of "if you were the defendant (and subsequently we were asked if we were the prosecutors), would you want a person in your current state of mind to sit on the jury?"

By the time I was called up and questioned, I had given it a great deal of thought. The answer was uneqivocally yes; and I answered to that effect. I admitted to a family history of violence and that I am a social worker by profession. By the time the jury questioning was over, I had been asked many times whether I felt I could fulfill the duties of juror. And each time, the answer was yes. So, in the end, I guess I shouldn't have been surprised to have been selected.

Today, having heard most, if not all of the testimony, my fellow jurors and I will be charged with the awesome responsibility of quite literally deciding a man's fate. And I've wondered if I am being dramatic when I say that. To be truthful, I don't have any way of knowing what the penalty might be if he is found guilty as charged. But, nonetheless, given that it seems a fair assumption that the crimes with which he is charged will carry the risk of substantial jail time, I find myself feeling the weight of the responsibility.

How do I tie this into birth you ask? Well, as I sit there, I can't help but wonder if obstetricians, who in many ways carry a similar burden of awesome responsibility, truly appreciate the depth of that responsibility. Or are they too jaded to truly understand the impact of their actions or inactions?

In respect to obstetricians, I've heard far too many credible (yes, one of our jobs as jurors as charged by the attorneys is to assess the credibility of witnesses) accounts of OBs who, citing dubious scientific rationale, induce women, immobilize women, and yes violate women, to believe that as a profession, they carefully consider the "evidence" as well as the impact of their recommended interventions on the lives of women and their families. Do they, as a whole, engage in the kind of deliberate weighing of the risks of the proposed intervention as well as not using it. Nor do I see much, if any credence given to the fact that there are emotional considerations of interventions for women as well as concrete physical considerations.

For Obstetricians, has medicine become primarily defensive; an effort to avoid perceived potential consequences of inaction, in the form of malpractice suits? Are they more concerned with their own convenience than with the well-being of women and their families (and by the way, I specify families and not babies, because I feel confident that obstetrical decisions and events effect more than the mother-baby dyad)?

The truth is, I don't know the answer for certain, or as we've been cautioned throughout this jury experience, even beyond a reasonable doubt. But I do believe with certainty that these professionals should be asking themselves these questions on a constant basis.