Podcast: Breech Birth: Your Choices with Guests, Midwives Dr Shawn Walker and Emma Spillane

Breech Birth: Your Choices with Guests, Midwives Dr Shawn Walker and Emma Spillane

Season 1, Episode 3

Around 1 in 25 women will face decisions around how to give birth to their bottom first babies! But did you know the options are more than simply 'have a caesarean'? From helping your baby to turn head down, to physiological/vaginal breech birth, these little discussed alternatives are explained in this episode.

Joining me this week is Dr Shawn Walker, founder of The Breech Birth Network and Midwife Emma Spillane. Both heading up breech teams at large trusts, they bring some real expert insight into the topic of breech birth. The pair bring the perfect balance of the intellectual understanding of the risks and benefits of each choice, whilst providing a nurturing and women centred approach to the episode.

With a real focus on informed choice, you will feel equipped to open up conversations with your providers about your own birth experience if you find yourself needing to make decisions around breech birth.

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Transcript

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I know right now you have no idea what to expect from birth, what it's going to feel like, how it's going to pan out.

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Welcome to The birth-ed podcast, where we open up conversations about all aspects of pregnancy, birth and parenthood.

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Hi everybody.

Welcome back to The Birthed podcast.

This week, I've got two fantastic guests.

I have Dr.

Shawn Walker with me and midwife Emma Spillane.

Dr.

Shawn Walker is a lecturer at King's College London and The Breech specialist midwife at St.

Thomas' Hospital.

She's also director of The Breech Birth Network, a community interest company that provides physiological breech training across the UK and internationally.

Shawn is also a mum to four lovely boys.

And we've got midwife Emma Spillane, who is lead midwife for The Birth Centre and Breech Clinic at St.

George's Hospital London, and is training coordinator for The Breech Birth Network.

Emma is also mum to two boys and one girl.

So my reason, I suppose, for inviting Shawn and Emma today was obviously first and foremost because of their expertise in breech birth, but something else which is obviously crucially important to me and everybody at BirthEd is how much they value advocating and supporting women's choice.

And that is gonna be a big focus of this episode.

So Shawn, Emma, welcome to the podcast.

Thank you for joining me.

Thanks, Megan.

Nice to be here.

So I suppose let's kick off then with what sort of sparked both of your interests in breech birth?

Where did this kind of speciality or special interest come from?

Well, I started my career working as an independent midwife, expecting to look after low risk women and found that people seek out an independent midwife when they can't get what they want on the NHS.

And my second client wanted a breech birth.

And I supported her to birth in hospital because I wasn't at that time experienced, but I've always been a good advocate.

And gradually I became aware of just how much demand there was out there.

And so I worked with the hospital where I had trained as a midwife to develop a breech care pathway within the NHS, which is where I think we should be doing for general breech births.

And that's basically what I've been devoting my life to ever since.

Amazing.

Emma?

So I was lucky enough to see two breech births as a student midwife, and then breech just sort of followed me around after that.

And I always wondered why we had such little training on breech birth as a student, but were then expected, when we needed to, to be able to facilitate these births.

And I always wondered why we taught it as such an emergency when I'd seen these births happening so beautifully in many cases.

And then I attended Shawn's training in January 2017 and started teaching with her very shortly after that.

And have just, yeah, just had a massive interest in it since then about giving women choice, really.

I think that's what I'm so passionate about, is that enabling women to have a choice in their mode of birth and not just saying, needs to be a caesarean section.

Yeah, and that is from all of the women that I've worked with and sort of my experience.

That tends to be still the kind of default route that most women are kind of offered when it comes to breech.

So we do have an episode that is on caesarean.

So we're not going to focus too much on caesareans for breech birth in this episode, but hopefully we're going to highlight some of the kind of other options and things that are available to women when it comes to having breech babies.

So obviously this podcast is for moms themselves.

So potentially women listening might be in a situation where their baby is breech, they've been told their baby is breech.

What does that mean?

What does that mean for women?

At what point is a baby actually considered breech?

If somebody has heard this word sort of thrown around, what could that potentially mean for them?

Breech presentation means that the baby's head is up toward the top of the womb, just under your ribs rather than at the bottom.

It could be the buttocks presenting, sometimes it's the buttocks and the feet beside the buttocks, sometimes it's the knees.

Very occasionally, it's just the feet that are down and that situation can add a few more complications.

But basically, breech babies move around just like you would expect any babies to.

So at about 28 weeks, there's a fair number of babies are still presenting breech and gradually, one by one, they turn their way to head down.

And so at 36 weeks of pregnancy, about one in every 25 babies is breech.

And that's when it kind of triggers, hmm, now it's time to do something about this.

And there's all sorts of research about why that is the case.

But basically, around 36 weeks, that's when your midwife would say, hmm, it feels like babies breech.

I think we should refer you for a scan.

And at that point, you would be offered an attempt to turn the baby by pressing on the abdomen to head down.

And that's successful in about 50% of cases.

And that's an ECV, yeah.

It's called an ECV, which stands for external because we're pressing outside.

Cephalic, which is the fancy scientific word for head down.

Version, which is another needlessly fancy word for turning.

I was just in Stockholm this weekend and they just call it turning, which makes a lot of sense.

Okay, and so what about if babies are, if a woman is told at 28, 29 weeks before she reaches this kind of 36 week mark, where she might be offered an ECV and that's something that she could potentially consider, what else could she be trying?

Should she be trying?

Should she be concerned about it before that point?

Is there anything else kind of that they recommend that you would recommend for women?

I mean, at 28 weeks, I wouldn't be concerned about it.

Moving obviously more towards that 34 to 36 week gestation, then there are things that mothers can be doing to encourage the baby into a head-down position.

Things, alternative therapies, looking at acupuncture, mock Sebastian and maternal positioning.

So, there is active birth positioning, there's a website called Spinning Babies, and they do a lot of those positionings as well.

So, looking at those sorts of things, seeing a chiropractor that specializes in something called the Webster's Technique, and that can encourage babies into a head-down position.

And so, you sort of mentioned mock Sebastian there.

That's something that a lot of women that I work with end up sort of trying.

And I believe, correct me if I'm wrong, that the research shows that when that is in conjunction with either acupuncture or positioning, that can be effective for some women in causing a baby to kind of move into a head-down position.

Are you able to tell us kind of what that involves, what that looks like, what a woman, what if the woman decided that she was going to try mock Sebastian?

Where would she go?

What would she do for that?

So, mock Sebastian is a modality that is in alignment with things like acupuncture.

It's a form of traditional Chinese medicine, and it involves stimulating with heat by burning a herb called mugwort at a little point on your littlest toe.

It all sounds very kind of alternative at this point, doesn't it?

And it smells like wacky weed.

So, yeah, I have made it my business to find out about all of these things.

I don't think there's any particular risk in using mock Sebastian.

If I were 38 weeks pregnant with a breech, it's not the only thing I would rely on to turn my baby if I wanted to turn my baby.

But yeah, before you reach the point of 36 weeks, if you wanted to try these things, or even in conjunction with external catholic erosion, ECV, then it's not such a bad idea.

But the way that a woman would access mock Sebastian is to see someone who's either trained specifically in mock Sebastian or to see someone who practices acupuncture.

And is that something that's ever available on the NHS, or is that a sort of private...?

So some hospitals do offer it.

There are some midwives who have done the training.

It's actually quite simple training to do.

It's really a one-day course.

So there are some midwives that are offering it on the NHS, but many hospitals haven't quite opened their criteria up to using alternative therapies yet.

I think it's something that's becoming...

There seems to be more talk about alternative therapies within the NHS.

So it may be something that we see more of coming in, especially with breech clinics being set up to support women.

Then it's something that I certainly would like to do to be part of my practice.

I think it fits well with that service.

Yeah, okay, fantastic.

And obviously on the Spinning Babies website, which you already mentioned, there's kind of all these other, I suppose, kind of fit into the alternative medicine practice or just kind of, I don't know, old wives' tales, kind of alternative things.

People say using sound or music or using ice or these kinds of things.

Is there any logic or sense in them or is it just kind of?

I think the thing to remember is the reason why ECV is offered by the NHS is because it's the single thing that has been proven by loads of research to be successful at turning a baby, but not increasing the risk just compared to someone who has not had an ECV.

So that's why we offer ECV.

And I am well open to women doing anything that they feel drawn to doing, unless I will be very upfront with someone if I feel that what they're doing is potentially dangerous.

Yeah, absolutely.

A lot of the things aren't potentially dangerous, but what they are is potentially very expensive.

And what I don't like to see is a situation in which women feel that they need to go out and spend thousands of pounds trying to turn their babies so that they can have a natural birth.

And I think at St.

Thomas' most of the ECVs at the moment are performed by two midwives.

And I think we use a firm but gentle procedure that most women are quite happy with and have had good experiences with.

And we listen very closely to the woman and don't continue if it's unusually painful.

Because if it's going to be successful, you know pretty soon, and in fact most women were finished in under two minutes and they're like, is that it?

I said, yep, that's it pretty much so.

But it's not like that for everyone.

So unfortunately it isn't successful for everyone.

But it's always worth a try if what you want to do is have a head-down baby because you want to go back to your plan of having a home birth or you want to have a water birth.

Neither of which are really recommended if you have a bottom-first baby.

Yeah, cool.

And also if your baby's head-down, everyone has the skills to care for you.

The single thing that makes the most difference on the safety of a vaginal breech birth is having someone in the room who is very experienced attending breech births.

Not just has had some experience, but has a significant level of experience.

Yeah.

I'm going to get on to that in a little minute when we move on to the kind of the birth itself.

But let's say a woman is 36 weeks.

She's accepted a scan, a presentation scan.

They found out, yeah, baby is breech.

Maybe she's bottom first, whatever.

Let's say she's, you know, spoken to her midwife consultant, whoever has decided, yeah, I think an ECV feels like the right choice.

What would that look like?

What would that appointment look like for her?

She was turning up presumably to the hospital.

Yes.

So, I mean, different trusts will run their clinics very slightly differently.

Certainly, ours happens in the hospital.

It actually happens on our main delivery suites on the labour ward.

And they come in in the morning.

It used to be that women were advised not to eat anything beforehand, but now we, you know, we tell women to eat and drink as normal because it is, has been seen to be a very safe procedure.

So they would come in, they would have some monitoring done of the baby to start off with just so that we can get a baseline of what their baby's heart rate is.

And then the, some, some services offer a drug to relax the uterine muscles.

It's called tabutiline.

Some, some services don't use that medication.

So it is something for women, it's worth them asking about.

Then they, so they would be, if they, if the hospital uses that medication, they would be given the medication.

It takes about 15 minutes to work.

Then a doctor or a midwife would come and scan the tummy, look at exactly what position the baby is in, and then perform the, the ECV.

The procedure itself usually doesn't take any more than about 10 minutes.

And as Shawn said, the ones that you know are going to be successful tend to happen very quickly.

You do tend to know very early on whether a baby is going to move or not.

After the procedure, whether it's been successful or not, we do some monitoring of the baby's heart rate just to, for about an hour afterwards to make sure the baby is happy afterwards.

And again, just scanning just to check what position the baby is in after the procedure.

And then they, you would go home and just carry on with your normal day.

OK, fantastic.

Thank you.

And so, next sort of question I guess is do we know why babies find themselves in a breech position?

Are there any reasons why a baby might be in that position or is it just a complete variation of a normal presentation for a baby?

It's a little bit of both.

So that's why every woman who has a term breech, that's what we call it after 36 weeks, a term breech presentation would have a detailed scan.

Because one of the things we're looking for is, is there any reason?

So there might be a reason, like the placenta is very low.

Or maybe the woman has fibroids that are preventing the baby from turning.

Reasons like that.

So occasionally we can see something on the scan that lets us know why this baby might be breech.

But usually we can't see anything except an apparently healthy baby.

Sometimes the baby also has less water or more water than normal around the baby.

But normally we see a perfectly healthy baby.

We see breech presentation more often for first time mothers.

And that's because they have tighter abdominal wall muscles.

And sometimes if the baby just hasn't turned by 36 weeks, then they're just kind of splinted into that position because she hasn't had a baby before, and the baby kind of ran out of room.

And so that's why we see breech presentation more in first time mothers.

It can also run in families either, and it can be inherited.

A tendency to breech presentation can actually come from the mother's side or the father's side because they think sometimes it has something to do with the baby's hips.

And that's one of the reasons also every baby who has been found in breech presentation, whether the baby has been turned down or turned to head down or the woman has given birth to a baby in a breech position by caesarean section or normally, then they will be offered a hip scan at six weeks.

And that's because breech babies are more prone to hip problems no matter how they've been born.

So even if they've been born head first or by caesarean section, there is a higher chance that the baby could have a congenital hip dislocation.

Very interesting.

So let's sort of move on now, I guess, to the birth itself.

And obviously, we kind of touched on this already, but, you know, in my experience working with women antenatally and also in kind of preparation for this episode, I spoke to a lot of women who either currently have a breech baby or who have, you know, given birth either by c-section or vaginally to breech babies over the past couple of years.

And the kind of recurring theme that came up, I'm sure you are incredibly familiar with, is that the vast majority of these women did not realize, did not know that there was any choice involved in how they birthed their baby other than potentially the date of the caesarean.

And that's kind of about as far as the choice element went.

So I suppose something that this episode is kind of here to highlight is what the kind of other options are around birthing a breech baby.

So we know that a caesarean is an option that is offered to women.

What is the current guidance?

What is the current recommendation?

What should women who are turning up at 36, 37 weeks, ECV hasn't worked or they've decided that they didn't want to have an ECV?

Or what do the current guidelines in the UK kind of say that they should be told?

So the RCOG guidelines in 2017, so that's the latest national guideline that we have, they are actually supportive of offering vaginal breech birth as an option for women.

They have a suitability criteria for women, but actually I think what is really important is that we do an individualised assessment on all women, because every pregnancy is different, every person's medical history is very different.

So I think it's not so much about having this kind of criteria that women should fit in, but it's about having an open discussion, reviewing all of their history, and then being able to make recommendations going alongside that.

So I think if there is absolute contraindication to a vaginal birth, regardless of which way your baby is facing, whether it's head down or bottom down, then that's going to be a very different conversation.

However, other than that, if your baby was in a head down position and you would be offered a vaginal birth, then it's about tailoring that conversation to their own risk profile, as it were.

I don't like the word risk really, but that risk profile.

So exploring all their options.

OK, fantastic.

OK, and so why was the...

Where did the recommendation for cesarean for breech birth come from?

Well, breech births had been declining for quite a while, for decades before the big study was done.

And when I say the big study, I'm referring to the term breech trial, which was done at the end of the 20th century and published in the year 2000.

And what happened in the term breech trial is that women were randomized to either a vaginal birth or a caesarean section.

What randomization means is that you agree to participate in the trial and someone randomly decides you're having a caesarean section or you're having a vaginal birth.

And in scientific research, this is thought to reduce bias.

So you're not just picking out the best candidates and they're having vaginal births, and then you're saying, see, it's all safe, while the difficult ones all have a caesarean section.

So it's trying to divide them up to limit the bias as much as possible.

And that study concluded that it was safer to have a caesarean section by a pretty significant margin.

However, there were some criticisms.

When they say safer, what does that mean?

Safer for mum, safer for baby, what do they look for?

Safer for baby.

For mums, it actually ends up being six in one, half a dozen, the other, because the safest thing for mum is always to have a vaginal birth.

Even though there can be complications, there's so much less than with the caesarean section, both in this pregnancy and in future pregnancies.

But the complications associated with a caesarean section performed in labour are a little bit higher, and, of course, a certain percentage of women are going to need that anyway, just like they do with head-first births.

So because a plant's caesarean is a little bit more controlled, then it kind of balances out.

So you have the lowest and the highest risk situations on one side and the kind of middle-of-the-road risk on the other side.

That's why.

So for women, it's equal.

In the term breech trial, the risk for baby was about three times what it was in terms of death or serious illness following the birth.

But, like I said, there were criticisms, one of them being actually the centres who had the most experience.

Quite a few of them refused to participate because they said, we know we have good outcomes.

Why would we randomise women to a caesarean section that they don't need that creates needless harm?

So then you have experienced people not participating.

In this sort of randomised, controlled trial way of doing research, you also have women who know.

So I've had four normal births.

If one of my babies had been breeched, I would have laughed at anyone who said that I couldn't birth my baby vaginally, because my first baby weighed 10 pounds.

So, yeah, I'm going to say no, thank you.

I don't want to take the chance that I'm going to have her 50.

So kind of the best birthers themselves are choosing not to even participate.

And then you also have the criticism that in real life, that is what we do.

We recommend you're a good candidate for vaginal birth when you're a good candidate for a vaginal birth.

And we recommend even if you fit the selection criteria, which I agree with Emma, all these things are terrible phrases because it's like who's doing the selecting, right?

And I guarantee you from having worked with breech for many, many years, the women that you would select aren't always the ones who want to select a vaginal birth.

So, but, you know, you might have a sense that even those women meets the selection criteria, actually this is a higher risk situation for whatever reason.

And you would recommend that she have a section.

And that's why in subsequent research, there was a very large study which has very much influenced our UK guidance, where many, many centers from France and Belgium, where they had a high degree of experience.

They looked over the course of a year, and I think 120 centers, how many, what was the difference between cesarean section and vaginal birth.

And they found no difference, because these are very experienced centers.

So that's the difference between that and the TurnBreech trial.

The big question, and this is what I'm trying to work on answering, because a large part of my role is to do research, is what does that mean for the UK?

Are we France and Belgium, or are we TurnBreech trial, or something else?

Do you know?

What do we give women about what they can expect if they birth a breech baby in the UK?

We don't know that actually.

We don't know that actually at the moment.

The RCOG guideline gives us a ballpark figure that we give to women when we counsel, which is the risk of perinatal mortality, which is of the baby dying, is about one in 2,000 for a caesarean section, because unexpected things always happen.

It's about one in 1,000 if you have a head-first birth, so if your ECV is successful.

And it's about two in 1,000 with a vaginal birth.

So you could look at that two ways, either it's four times as risky to have a vaginal birth, or it's two in 1,000, which is still a pretty small risk, but nonetheless it's one that we need to be very respectful of.

Yeah, and I suppose the way that you've described it there is perfect, because often, as again, I'm sure you're aware, the way that this kind of information around chance or risk is presented to women when something is presented as four times more likely.

For a lot of women, that's quite a frightening statistic.

It makes it sound kind of massive, but when you hear the statistics and the figures themselves, that's putting people and women and partners in a much more informed place to interpret that risk or that chance in whatever way that feels right for them.

For some people, that will feel like a chance too big, and for some people, it will feel like a very, very minute difference.

And so it's so important, and particularly something that I always recommend to the women that I'm working with is that when you're accessing information, to ask for exactly how Shawn just described it, rather than listening to four times or twice as likely or 50% or whatever, because that isn't giving you hard statistics, and that's the information that women need.

So we've talked briefly about that term breach trial, which is kind of where the kind of guidance that we've got at the moment comes from.

Now that changed practice quite considerably, quite quickly, didn't it?

And has that now put us in a place where, you know, you've mentioned already the importance of having an experienced midwife practitioner looking after you in labour.

If the vast, vast, is it some 80, 90% of breach births in the UK at the moment of cesarean?

About that, yeah.

So does that put us in a situation where the likelihood of women meeting midwives who are actually experienced, not just trained, but experienced in supporting vaginal breach birth, if that's something that they want to explore?

What does that look like for most women in the UK at the moment?

Yeah, I mean, it's put us in a difficult position.

And I think particularly with the new national guidelines that have come out, which are actually saying to mothers, this could be a suitable option for you, we're in an almost danger period where we have research, evidence and guidelines that are supporting vaginal breach birth, and yet we haven't got the practitioners in all settings that can support, skillfully support and facilitate these births.

So, having, I think, we know that having a skilled practitioner in attendance to assist with facilitating the birth or support staff to gain the skills to facilitate the birth, just having them present will reduce the chance of any adverse outcome, it improves safety, and I think that's the single most important thing that should be put in place.

And I think there are hospitals that are now moving towards developing these sort of breech teams so that they can provide skilled attendance at birth.

And I think that's important, so I think any mother that is looking at the option of having a vaginal breech birth, this is definitely a question they should ask.

How can that hospital support that birth safely?

Do they have skilled practitioners that can be in attendance?

Can they arrange a kind of on-course system for those people to be in attendance?

Because we don't, there's not an abundance of skilled practitioners as a result of the decline in facilitating breech births.

And I think we have a different type of breech experience now.

So what's happened is, we haven't actually talked about this, but there are the breech babies that are found to be breeched at 36 weeks, and there are the breech babies that are not found until they come into labour.

And in some places, that can be as high as 20 to 30% of all of the breeches, which, if you do the maths, means anywhere from 1 in 100 to 1 in 125 women, all women, not just women with a breech baby, but 1 in 100 of all women could have what's called an undiagnosed breech baby, which means that the baby is not discovered to be breeched until they come into the hospital and are in labour.

Yeah.

Okay.

And so, what's happened since the term breech trial is that the majority of breech births have been undiagnosed, and they're often both undiagnosed and very quick, because if they're not very quick, they end in caesarean sections.

So the ones that...

And that's why, like Emma said, a lot of the training that is provided is training to deal with a breech in an emergency.

Like you are there on your own, the bottom is coming, and you're just going to have to deal with it, okay?

So any experienced midwife, if you've been a midwife for 10 or 20 years, most experienced midwives working in midwifery settings will have experienced supporting this type of undiagnosed breech, which tends to happen very, very quickly.

And then there can be a sense of like, well, what's the problem?

It's a variation of normal.

What's the big deal?

They just fall out.

However, what we have lost in this time of sectioning all of the breeches that we can possibly get into theatre is we've lost the ability to evaluate when a breech labour is going well or when it's not.

Okay.

And this is where the skilled practitioner, it's very important during that pushing stage where the baby is getting really, really cramped.

You know, this baby is folded in half like a taco coming through your pelvis.

And we need to keep a very close eye on making sure that when the baby gets cramped, the cord isn't also cramped and things like that.

And we have to constantly make judgements.

Is the baby going to come out quick enough that that's not going to be an issue?

Or does it look like that might be an issue?

In which case...

So it's not just about being able to do maneuvers at the last minute.

And in my experience of having done many, many debriefs with people who are trying to understand why things turned out maybe not as well as they would have hoped.

For example, everybody worries about whether the head won't fit through the pelvis.

But an extended head that becomes trapped is more likely to happen after you've had a baby that has become compromised through the process of labour.

So yes, it's the ability to deal with the head so that the head doesn't get stuck.

But actually, if the baby is not compromised, that's very rarely very difficult.

So that's what Emma and I have been working so hard on many weekends away from our family to try to teach people how we can reintroduce the skills of attending planned breech labours, which aren't necessarily as quick as the ones that we observe in undiagnosed breech births.

And you just quickly mentioned the sort of difficulties arising more commonly when there's compromise in labour of the baby in some way.

And that's exactly the same as in a cephalic or a head down baby.

So that's not special to a breech situation.

It's exactly the same as any vaginal birth, isn't it?

And so let's talk about that.

Okay, planned breech birth.

What does this look like?

And what could it or should it look like in terms of where women are, what that environment is, who is around her?

Because, you know, it's quite easy in our heads to think, okay, great, plan a breech vaginal birth.

It can still look exactly how I imagined it would look if it was a cephalic head down baby.

But sometimes the realities of that, and it's going to require potentially a bit more of a conversation on the woman's part, it doesn't necessarily, the kind of health care provider's idea of what a vaginal breech birth is going to look like for this woman and the idea that she might have in her own head may not kind of initially look exactly the same.

Yeah, and I think...

I've run the clinic at St.

George's.

A number of the women that have wanted to plan a vaginal breech birth are the mothers who actually were probably planning a home birth or a birth center birth previously.

And then they're exploring this option of having a vaginal breech birth and generally quite motivated to do so, but they want to keep some aspect of that original birth plan in place.

And I think that can be difficult for the provider sometimes because especially if they haven't got, it's not something they're seeing all the time and they know that there could be some slightly increased risk associated with the birth.

Generally the recommendation is to be on an obstetric-led unit, so the main delivery suite where they have doctors present all the time.

And quite often they will offer continuous monitoring in labour.

And sometimes women don't want to have that and I understand that as well.

I think it's about talking to the mothers and coming up with a plan together.

And you can give recommendations, but if this is an otherwise uncomplicated pregnancy, then there's no reason why you shouldn't be able to support some of those wishes of the mother, even if it is on an obstetric unit.

And I had a mother just recently who really wanted a birth center birth and actually in early labor, we facilitated her being on the birth center for a little while so she had some of that experience.

But then we set the room up on the obstetric unit, exactly how we would have done on the birth center.

So we had low lighting.

She was in a corner of the room because she just wanted her own little cocoon to be in.

And she was on a mat and she had a birth ball that she was leaning over.

And it was brilliant.

It was a really lovely atmosphere.

And for the birth, she did come up onto the bed for the birth, but she was in an upright position.

She was encouraged to be mobile.

So there are definitely ways of supporting the birth plan.

I always talk to mothers about who will be present for the birth.

And I would...

So we always say to them, there will be a doctor present just in case, that we need their assistance in any way.

And I would expect them to come in and introduce themselves to the mother and not just come in for that second stage.

And I always talk to them about having a baby doctor present as well, just in case baby needed any resuscitation.

And it's good to be prepared and have them there.

I also actually talk to them about having another midwife present, because it's very difficult to document and facilitate a birth.

So either I would support them to facilitate the birth and document for them, or we would do it the other way round.

So they know that these are the people that are going to be present.

I also talk to mothers beforehand that if there was an emergency situation, the same as any birth, even if it was a head-down birth, that we would get extra help in the room.

And sometimes that can happen quite suddenly, and sometimes that can mean there are suddenly a lot of people present.

And I think if we can have conversations about this before, in the planning stages of the birth, then mothers are much more relaxed about it.

And when it does happen, it's not such a scary thing, because they've had that conversation, they knew that something like that could happen as well.

Yeah, and obviously, with a breech vaginal birth, in the same way as any vaginal birth, the sort of emotions that a woman is feeling, the environment that she's in, the positions that she's adopting is all just as important, or probably more important, with a breech vaginal birth than it is in a sort of head-down baby.

So it's important, would you say, for women to make sure they've had that conversation before, if they know that they're planning a breech vaginal birth, to kind of come up with those agreements.

So they're not suddenly picturing one thing and then turning up and finding out they've got to give birth in theatre or something like that.

So that conversation happens antennately.

And I find, I mean, we know that when women attempt a vaginal breech birth, their chances of having a caesarean section in labour is slightly higher than it is with a head-down baby.

And it's slightly higher if you've had an external catholic version than if you've never had your baby turned as well.

But I find because we do so much counselling with women who are making a plan for a breech birth that if that happens, it's actually not nearly as kind of shocking as a woman who is expecting to come in and have a straightforward, low-risk water birth who then finds that one of the occasional unforeseen events happens and she needs a caesarean section.

I think that sometimes that can actually be more upsetting or shocking than the woman who knows that that's a good likelihood anyway and has already kind of wrapped her head around that possibility.

But that's one of the reasons why it's such a...

When you have a breech team and there is some continuity and you establish trust, because one of the dangers in our current environment is when women have to fight to plan a vaginal breech birth, they don't know who to trust.

If someone is saying they need to have a section in labor, the plan needs to change now.

And sometimes that needs to change really quite quickly.

If they have had to have a lot of confrontations just to plan what our national guidelines say they should be able to plan, then it's hard for them to know, I need to trust this advice and accept it.

Whereas I feel pretty confident that people know that I spend my life trying to support Vagina Breach Birth to be as safe as possible.

So if I'm saying you need to have a section, I don't say that lightly.

If I'm saying we need to perform an episiotomy, which is a small cut, because otherwise your baby may be in danger, she knows that I'm not just doing that because I'm frightened.

I'm doing it because there's a need.

Yeah, and it's that trust of that continuity is sort of like, it's the single biggest intervention you can make, isn't it, to kind of improve outcomes for women and babies?

It is, and it's across all risk categories.

The continuity makes a huge difference to the safety, and it's hard for us to describe exactly why that is the case.

But then when you start looking at individual case studies, it's pretty easy to see.

Yeah, and that trust and that call of judgment is kind of probably quite a big aspect.

So some of the women listening to this podcast might be in the lucky position where they've got a team of midwives, a breach team, a team of healthcare professionals.

With people like you on it, great.

Who they can go, they can ask questions to, they can trust, they can build that relationship up with.

But at the moment in the UK, having a designated breach team isn't a reality in all hospitals.

So if women find themselves in a position where actually there isn't an experienced care provider in the hospital at which they're booked, what would your recommendation be?

If they're listening to this and they're due next week, we can't necessarily wait for all hospitals to potentially kind of catch up with this provision.

What would you suggest?

Where should they look for support?

Should they change trust?

Should they seek out the support of an independent midwife?

Like, what would their options be?

Well, I would first recommend that they get in touch with their consultant midwife.

I know there's a shortage of those as well, but I would like to think that any consultant midwife will firstly know how to navigate the local system to see if maybe they've talked to the wrong people and maybe they could put a plan in action in the hospital where they're booked.

The consultant midwife has access to a network of consultant midwives as well, where they could find out where a nearby referral could be possible, so a woman could ask for that.

There's also support available on social media.

So, for example, there's a Facebook group called Breech Birth UK, and women often will share experiences and share advice, and they might be able to find out where there is a local breech clinic.

Independent midwives also are bound to know this information, and if a woman feels it's safest to have the support of an independent midwife while she's birthing locally because she's uncertain of what she's going to encounter when she gets to the hospital, then by all means, I mean, I wouldn't want to dismiss that as an option because that's how I got into this.

So I think that, and it is up to each independent midwife to know where her limits are as far as offering a home birth or supporting the woman to navigate the local NHS system.

But I feel very confident in my independent colleagues to be able to do that.

Yeah, absolutely.

And kind of final thing then, if a woman is in a position now where she's got to make this decision, she's got to decide, does a cesarean feel right?

Does an ECV feel right?

Does a vaginal birth feel right?

Do you have any tips on what she should do to make a decision that feels right for her?

I think get all the information.

You know, there's some bad information out there, don't get me wrong, but there's some really good information out there as well.

I always signpost mothers to the National Guideline and I also signpost them to a leaflet which is publicly available on our website so that they have some balanced information there to help them make a choice.

And I also think find out what's available to you in your trust, in the hospital you're booked with.

Is there support there?

Or is there support in the local area?

So are there other hospitals that are supporting a service that you could go and explore the options?

And then, you know, once a mother has all the information, they will make the choice that is right for them.

And I think that's important.

It doesn't matter what decision that is.

It doesn't matter if she opts for vaginal birth or she opts for a cesarean section.

I think what is so important is that she's been able to gather all that information and make a decision based on how, you know, she interprets that information.

And we all look at, you know, we all interpret risk differently.

So I think that's what my advice would be.

Absolutely.

Emma, when I counsel people in my clinic, the most important question I ask, and I try to ask it fairly early on, is what's important to you?

And I think that women make instinctive choices as well.

And to a certain extent, if I know what's important to women, I can help guide those choices.

So, for example, if this is your first baby, you are 24 and you come from a family of large families and that's what you're planning, then it's probably a good idea to have an ex-tranacovalid version and or a vaginal breech birth, because the benefit for you and future babies is really, really significant.

If you tell me, actually, I'm really scared, I'm not sure, I just don't think I can do that and I think I would be worried, I don't want anyone to lose sleep at night, okay?

And if you're frightened, vaginal breech birth, it takes a bit of fortitude, let's put it that way.

I don't think it's something we should be pressuring anyone into.

Absolutely.

At all.

And I think that if a woman instinctively feels that's not right for her, it's probably not safe for her to attempt it, you know?

And so what I like to say is that by far, the most likely outcome, no matter how you choose to give birth, is that you and your baby will be well at the end of it.

Sadly, that isn't the case 100% of the time and so we need to discuss the potential adverse outcomes that could happen and as health professionals, we need to be really mindful and aware and respectful of those.

But still, at the end of the day, for the majority of women and babies, the most likely outcome is that they and their baby will be well.

Great.

That's a really good, I think, point to kind of wrap us up on.

Thank you so much for joining me today.

That has been incredibly insightful.

And I hope all of our, I hope that's given our listeners just a tonne of information that they potentially haven't got in a kind of 15-minute midwife appointment where they've suddenly heard that their baby has breeched.

Hopefully that's going to kind of answer a few of the questions and give them kind of a good starting point to go forwards and chat about their own kind of specific circumstances with the people that are there to look after them and their babies in their pregnancies and births.

So the final thing that we kind of end all of our episodes on is just a question for each of you.

And the question that I've got is, if you could gift pregnant women one thing or labouring women one thing, what would it be?

Mine would be a service that meets the needs of mothers and their partners and not a service that meets the needs of healthcare professionals.

Hooray!

Yes, please.

Shawn?

One of my colleagues has this fantastic phrase when someone is worried about something.

She says, I'm in your pocket.

So if I could gift every woman something, I would gift her her very own midwife in her pocket that she has a known and trusting relationship with, that she has 100% confidence in.

A person who gives her confidence in herself.

And so this is a kind of blow up midwife that you take out of your pocket, who kind of suddenly becomes a real life figure who is there to keep you safe.

So I am gifting every woman a midwife in her pocket.

A little inflatable midwife.

Amazing.

Thank you very much.

So just finally, before we go, if there's anything that you want to sort of plug, if you want to mention The Breech Birth Network or anything like that before we go, where can people find you?

So we have a website, breechbirth.org.uk, and there's lots of information on there.

There's the leaflet, there's research, a lot of which Dr.

Shawn has done.

To be honest, it's hard to do a web search and not find us.

There's not much.

Fantastic.

Thank you so much.

And that's going to wrap us up for today.

Thank you so much for listening to this week's episode.

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