Pregnant for the second time, we planned a home birth as we had with our first daughter Lucy. Our care with an independent midwife and a doctor had been perfect and the birth a wonderful experience so we were happy to go this way again. This time around we also had two midwives.
Holly had chosen the breech position from about the 34th week. When it was first suspected by our midwife through feeling my tummy, we thought little of it. Whilst about 20% of babes are breech at this time, by term the rate has dropped to about 3-4%. So I just thought, "it'll turn". However as the weeks progressed, Holly's upright position caused us increasing concern. I really wanted to birth at home but we all considered it unwise with a breech baby and I set about coming to terms with the reality of having to move to hospital for the birth. Our doctor and both midwives were still confident that she could turn and if not, that vaginal birth was still possible in hospital particularly with them advocating for me. 35 weeks came and went. This was a significant date for me as Lucy was born at home at 35 weeks. I found it hard not to presume Holly would do the same thing. She was determined however to show me how different to her older sister she really is.
By 36 weeks I had become fairly obsessed with gathering information on the risks associated with vaginal and cesarean breech birth. I talked to as many midwives and mothers as I could who had experience of breech birth. It became apparent to me through my research that whilst I had an increased chance of a cesarean birth due to Holly's position, there was plenty of evidence to support a vaginal birth. There have been no randomised control trials of adequate size comparing planned vaginal breech birth and elective cesarean section. In the two small randomised trials that have been done, the two groups showed no difference in perinatal mortality or Apgar scores. What I had come to understand, and this made commonsense, was that an active labor assisted the breech delivery (and all deliveries one would think). Furthermore standing was the most efficient posture for the mother to deliver the baby (as it enables maximum opening of the pelvic outlet and uses gravity to assist descent).
At 37 weeks I decided to try an external cephalic version (ECV) to turn her. My understanding from the reading I had done was that the success of ECV was quite high (about 60%) in multiparas (mothers who have previously given birth) however success depended on a relaxed and willing mother and a skilled and patient practitioner. The procedure was my first experience of a medical nature with either of my babies and it did not endear me to the medical model of care. I expected that the obstetrician who conducted the ECV would talk things through with me and give me time to relax into it. Instead he walked in and said "so we have a big head do we!!". He had misunderstood the facts, as this wasn't the case at all, however my midwife, Tony and I all flinched. The last thing we needed to hear was that! It had us all worried to start with. He then informed me (not asked me) that a doctor would stand in to observe the procedure. I don't have a problem with this at all actually. What I have a problem with is not being respected enough to be asked. Then he slapped gel over my tummy and I thought he was going to have a look at Holly using ultrasound and would then talk to me about the procedure to prepare me for it. However after a quick look, he just started - he didn't even say he was going to start. He kept referring to measurements and commenting on the baby and I kept having to ask him "are you talking to me?" I was never quite sure whether he was addressing the other doctor or his assistant who was typing data into my record sheet at the same time. I did not feel relaxed as he tried to turn Holly. She was now a frank breech (legs straight up beside her face) making it difficult to turn her as the legs form a sort of splint preventing her from being able to roll around. It was very uncomfortable, even painful, and the whole experience had me in tears. He concluded suggesting I needed to "consider my options"! but I know he was thinking "cesarean for this one".
As the tears streamed down my face he did his best to console me by pointing out that whilst home birth is a nice idea, in the end all you really want is a healthy baby….blah, blah, blah. In fact he missed the point. I was very disappointed at the prospect of not having a home birth, and indeed afraid of the possibility of a cesarean. However at that point I was grieving my loss of choice. I didn't really want to be cheered up and least of all to be patronised about my home birth decision as though it was a silly thing to have chosen in the first place. My midwife and Tony understood and just held my hand and stroked my head. They were just with me whilst I felt my sorrow.
We left there and after some deep breaths we "re-grouped" and decided that as we were near the Royal Women's Hospital (RWH) we may as well have a look just so I can get used to the surrounds. We went up to the labor ward and asked to see a room. I walked in and just burst into tears. Reality was looming. However the midwives there were friendly and helpful and my midwife quizzed them on the best "team" to aim for in terms of maximising my chances of a vaginal birth. "Tuesday's" they all responded immediately in unison. There wasn't much doubt about that so we booked in for an antenatal check the following Tuesday. All along this journey, as time ticked away I had a nagging fear that I would go into labor before I had it all "sorted out". I was to learn there is only so much "sorting out" you can do. After that you really have to hand it all over.
Tuesday came and I turned up for my 9.40 appointment and the RWH but didn't see the registrar until close to midday - a normal delay apparently. This was just one of the many differences in the quality of care I was to receive through my own doctor and midwives , compared to that offered by mainstream public care. With my chosen team, we always had time to talk. My options were always discussed and the focus was on the baby and I rather than the institution and its procedures and protocols. We developed a rapport that enabled me to be able to discuss my feelings, both positive and negative and claim the experience as my own, no one else's.
However the registrar at the RWH was a friendly woman and at least had the courtesy to ask me if I minded there being a student present. We then sat down to discuss my situation. She informed me that it was routine practice with a breech baby to administer an epidural on arrival and connect the mother to continuous EFM. I told her I didn't want either. An epidural and continuous EFM would surely ruin my chances of an active birth and standing in delivery. From my reading of the literature I could find no evidence that an epidural is indicated or has shown to offer any unique advantages for term breech pregnancy. Most likely I would be on my back in the stranded beetle position, closing my pelvic outlet, prolonging labor and increasing dramatically the likelihood of a cesarean. She told me it was my choice not to have an epidural but I must understand that if the head got stuck due my cervix not being fully dilated, I would have to have my cervix cut without anesthesia in order to get baby out alive. The thought of being in that position frightened the hell out of me.
She informed me that they would also want to do an x-ray of my pelvis to ensure it was large enough for the baby to pass through. I was also reluctant to do this due to exposure of myself and the baby to radiation and I had little faith in it as an accurate indicator of my pelvic capacity in labor. No studies have confirmed the value of this procedure in selecting women who are more likely to succeed in a vaginal breech birth or in improving perinatal outcome. Given the freedom to be active and standing in labor, the pelvis can open considerably larger than its normal size. It would only be limited if I remained immobile and on my back!
No other management techniques were discussed. I timidly asked for the hospital statistics on vaginal breech birth and they were unavailable however it appeared that they were negligible for first time mothers and low for multiparas.
What was never raised or discussed with me were:
The risks associated with an x-ray of my pelvis including exposure to the baby.
The reality that with EFM and an epidural I would not be able to be active in labor.
The increased likelihood of a cesarean section if I had an epidural and EFM.
The risks and complications associated with cesarean birth in comparison to vaginal birth.
This represented another difference to my experience of antenatal care with my own doctor and midwives. Here, I was being told what the system does. The information I was being given was directing me to comply with the institutions model of care. What I had come to expect was that my baby and I were the centre of care and having expressed my needs and desires, my carers would work in partnership with me to deliver care congruent with those needs and desires. This was not naďve care either. What it aimed to do was enable me to be in control of my experience within the context of any complications that arose including the breech birth. So whilst genuine complications may limit my choices, alternative courses of action where still taken with my needs and interests at heart. A medical complication doesn't by default remove the woman from the equation.
I left the hospital feeling confused and doubtful about my innate birthing ability. I had felt intimidated negotiating my options, even with all the reading and research I had done, and found myself reluctant to ask questions or to question their protocols. Instead of encouragement and support I was merely presented with the worst case medical scenarios. I felt like I was heading on a fast train toward a cesarean and I would have little or no control over this birth. Even with my own doctor and midwives with me I felt I would be too vulnerable. My entire confidence was rocked, and this was the Tuesday team!!!!
It wasn't so much now that I feared hospital birth or even a cesarean section although obviously neither was my preference given the choice. I had accepted that this might be a case where intervention would indeed be warranted and helpful. What I feared most was that I would undergo unnecessary intervention due to routine procedures and protocols rather than genuine necessity for a real complication. I couldn't trust that my choices and needs would be respected or that they would influence the management of my labor. The public system was a lottery at best. That wasn't good enough for us and so my doctor recommended a private obstetrician, whom he believed would be supportive. We were to meet with him in my 38th week. I could really hear the clock ticking now!
I was fairly cynical by this stage and although much hinged on the outcome of this meeting I didn't get my hopes up. When I met with him I was soon reassured. He had talked to my doctor and read my notes and his first question was "how do you feel about all this?" Aaaah!!, off to a good start here. I explained exactly that, how I felt. I told him I accepted the need to be in hospital however I was very concerned that the management of my labor would be highly interventionist, limiting my chances of a normal vaginal birth. I explained that I was seeking a carer who would be willing to intervene as little as possible and only when an actual complication called for it. We then discussed each possible complication in detail and how they would best be dealt with. We managed to come to a mutual understanding of my desire for a low intervention labor and vaginal birth and his professional opinion about where it would be necessary to intervene including the need for a cesarean. I did not want continuous EFM and he was happy to perform intermittent auscultation. He accepted and respected without judgement my choice not to have a routine epidural. He was fine about me being active in labor and accepted my desire to stand for second stage provided all was progressing well. He performed a clinical pelvimetry (manual assessment of my pelvis) and felt that there was no reason I shouldn't birth my baby vaginally. He said he would like to do an ultrasound at the start of labor to confirm that Holly was still a frank breech and that the head wasn't flexed. If there was a cord prolapse, prolonged labor or fetal distress, he would want to do a cesarean. So we negotiated the labor management.
He respected my choices and the fact that I was the central figure in this birth. I respected his professional opinion and expertise and was able to accept his concerns about complications and the course of action he would feel compelled ! to take. I felt that we were in partnership making this decision. He also agreed that myself, my doctor and my midwives be part of the decision making process. The more we discussed all this in detail, the more reasonable I found him and the more confident I was to thrash out the various issues that may come up and need to be sorted out. At the finish of the consultation we shook hands and I left, feeling elated. I had really been listened to and I hadn't acted on the defensive. My confidence flooded back and I virtually skipped out of there. Importantly he had valued my understanding of breech birth and the issues involved. This enabled me in turn to value his. The only complication now was that he was going to be on holidays for the weekend!! He assured me that his backup would be fully informed of my situation and needs and be supportive in the same way he was, however now I felt compelled to "hold off" until Monday when he returned!
I felt pretty good over the weekend. I had accepted the seeming inevitability of a hospital birth and felt that with my doctor, midwives and this obstetrician as my team I had done everything I could to maximise my chances of a vaginal birth with minimal interference. I had also come to realise that there are elements of birthing way beyond anyone's control and at this point it was time for me to let go of trying to control the outcomes. What a powerful learning experience this was for me. In a sense it was like stepping off the edge of a cliff and trusting that there was a power for good working in my life that would carry me through this experience regardless of the outcome. We were going to be OK. It wasn't until I got to this point that I really felt that I could begin to let go. I could let go of all the "what ifs?" and all the research and musing over countless studies. I could let go of the fear of condemnation or criticism for making the choices that I was making and I could let go of the fear of pain and complications. My carers were the best I could get. They were supportive of my needs and now all I had to do was relax and let my body and my baby do what they knew best. I felt now that if I had a cesarean it would be because it was the right action to take at the time, not because the management of my labor was such that my carers were too unskilled or fearful to allow it to happen naturally.
Monday came and with the obstetrician back from a weekend respite I felt at ease. I was a couple of days short of 39 weeks now and all day I was thinking "whenever you're ready baby". I felt so heavy and drained and very ready to give birth, emotionally, psychologically and physically. I got on the phone in the early evening to a friend whose first baby had been breech. We had a great chat. She was so positive about her experience and so sure that mine would be just as positive. After our chat I felt filled with confidence and able to bring my focus within to my baby and I. After speaking to her I rang Rhea Dempsey, a birth educator and counselor of some 20 years experience of birthing in the home and hospital setting whose support I have found invaluable during both my pregnancies. I had let go of so much but still felt compelled to talk to Rhea. As we talked I realised that I still had a fundamental fear of the babies head getting stuck and all the associated complications that may go with that. I guess the comment of the obstetrician who tried to turn Holly and my experience in the RWH had really imbedded in my sub-conscious and were worrying me. However I had to remind myself that with the team I had supporting me and my preparation and readiness for an active standing labor, I was doing everything I could to prevent this complication and now I had to let go of that too.
I dimmed my bedroom light and lit a candle and meditated. Afterwards I felt so peaceful. I felt I had come to a place of purity in my mind. I had expelled all the demons. I had taken control of everything that it was within my power to control and then I had let go of all the other stuff which was totally out of my hands. I felt cleansed and serene. About 30 minutes later my waters broke and an hour and 25 minutes after that I was holding Holly in my arms.
When my waters broke it felt quite dramatic. I thought she must have put her foot through or something!! I literally felt it burst and the liquor ran out with a gush. I lay there for a second or two as a smile crept across my face. I said to myself, "I'm going to have a baby now". I carefully got out of bed and paced to the bathroom. As more water spilled into the loo, Tony called out, "that didn't sound like the half a teaspoon you normally do". "Its not", I replied and then I heard the urgent thump thump down the stairs as he came to investigate with me. "Its on", I said. Almost immediately I could feel contractions coming on and I phoned my midwife. I started shaking on the phone, from shock and excitement I suspect. We spoke briefly and she said she'd be over straight away. Within a short time the contractions were a minute apart and strong enough to make me stop what I was doing to concentrate on each one.
Only a few things remained clear to me during this time. One was that this was going to be quick and that was a really good thing with a breech birth. Secondly, I had to stand and rock my hips with each contraction and let all the sound out that I could. Finally, when it came to pushing I had to be standing. All the fear and anxiety was gone. I didn't even have to will it away - it had ceased to exist and I just had to go with what was.
The contractions were intense and with only seconds in between I tried to organise myself. My priorities changed with each contraction. Initially I was showering and trying to fix myself up for the trip to the hospital. Within a short time I had gone into "animal" mode, assessing each room in the house for the best place to deliver. With a bucket in one hand and a towel in the other I quickly settled into the bedroom. It was dimly lit and cosy warm - and it's where Holly was conceived. Tony was packing my bag, checking each item on the list, phoning the "team" and racing up to me for each contraction to offer support and comfort. We were both really busy!! He had phoned the midwives at the hospital to let them know I was in labor and I spoke to one of them who, as soon as she heard me was in no doubt that we should come straight in.
My midwife had planned to meet us at the hospital but when the contractions were a minute apart and really intense, Tony rang her again and asked her to come to our house. We couldn’t leave until Tony's sister arrived to look after our little one Lucy. Our midwife arrived about 40 minutes after I had originally spoken to her and confirmed I was 8 cm dilated!! Wow - this was quick. I was already starting to want to push too. "We need more support here", she demanded. Like clock work our doctor turned up soon after and a short time later our second midwife arrived. Whilst there had never been any intention by any of us to deliver Holly at home, the pace of the labor had meant that we had no choice. It would have been foolish to attempt to move to hospital as Holly would surely have been born in the car. Tony also called in Jacquie, our close friend and our support person at Lucy's birth. There was no way they could have got me into the car now. The contractions were one on top of another with no relief in between - much more intense than my first labor. I wanted to push so badly but my midwife knew that it was imperative that I was fully dilated and I needed to hold off. In the end I held off for nearly half an hour! My midwife has a wonderful breathing technique to help distract you from the urge to push. I had to do it with Lucy but not for so long. It was definitely the hardest part of the labor.
When my doctor arrived he checked my cervix and confirmed that I could push. Now I didn't know if I had the strength! I was kneeling on the bed and the midwife suggested I stand up. So I stood on our bed with Tony and her on either side supporting me. It was such a strong powerful position to be in. It only took about 3 contractions to push Holly out. I thought I was going to split in two as her little body emerged. She hung there a short time as meconium squeezed out of her tiny little bottom and then slowly her lips emerged, then her little nose, her eyes and out she came. The doctor supported her all the way ensuring her head wasn't in any danger. All I could say is, "my little girl", "I have another little girl". It was just so beautiful. We were all elated and much relieved.
The team got me comfy wrapping us both in warm blankets and supporting my back with pillows. Holly lay on my chest as the midwife gave her aspiration to ensure there was no goop in her lungs and then a little oxygen. I had a tiny first degree tear that wasn't stitched (and has healed beautifully) and all was well. Minutes later I gave a hefty push and the placenta slid out without any assistance. The whole labor was perfect, just as Lucy's was 2 years beforehand. It was so satisfying and as soon as she was born all that pain was over and I had this healthy calm, peaceful little babe in my arms. I was laughing. Then everyone raided the kitchen for cake and tea and we ate with gusto and celebrated Holly's arrival. This all started at about 10.10 and by 3.30 everyone had gone home, the house was peaceful and quiet and Tony and I were just lying in bed on the most incredible high with our tiny baby sleeping between us. It was magical. Life just went on.
The process of giving birth is about letting go in more ways than one. I am thankful to all the people I know who have shared with me their birthing knowledge and supported me on this journey. In particular my husband Tony who has stood by me through all the highs and lows of this experience. He has supported me in every choice that I have made and without his unconditional love and respect this journey would have been far more difficult one for me to make
I've heard it said that our children are our greatest teachers. Never has this been truer than in my birthing experiences. I learnt so much about myself in this process. I am left personally richer and stronger for having surrendered to this experience. I didn't give in, but recognised what was beyond my control and then trusted in a higher process - a powerful force within this universe beyond my own control or that of the institutional management of birth. I took a leap of faith and the rewards were immeasurable - the perfect birth experiences and two perfect, beautiful little girls. I am left feeling so fulfilled by my experiences that now, in my parenting, when challenges arise as they surely do, I can take control of the situation to the best of my abilities, and beyond that I can hand the situation over, say a prayer or ask for guidance and I know that it will all be ok.
Robin Payne, 1999
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