Courtney DoggartMay 1, 2017
I saw my baby's butt first. He backed his way into this world with his purple, un-oxygenated bottom leading the way. He was folded in two, in a perfect pike dive position. I was in the midst of the most strenuous ab exercises I'd ever done, the operating room lights blinding me like a mothership. Three or four residents, my OB/GYN, my mother, the anesthesiologist, and a couple of nurses peered down on me. After his hips emerged, the doctor aided his legs out one by one, until he looked like a tiny, headless baby trying to climb back into my body, reminiscent of Goya's Saturn Devouring His Son, except that my vagina was Saturn.
My son had been stubbornly breech—or head up—for as long as they pay attention to these things during the late stages of pregnancy. I had tried every trick in the book to flip him. My husband would routinely wake up to me crawling around on all fours in our apartment and return at night to me burning moxa sticks by my pinkie toes. (The heat cast from burning this herb is thought to release pregnancy hormones that stimulate the baby to move.) I hung upside down off the side of my bed with ice packs on my upper abdomen and music blaring near my pelvis. I found a local pool and did headstands and somersaults in the shallow end while the elderly Asian men who used the pool looked on bemusedly. I paid far too much for a special Mayan massage, which supposedly puts the uterus in the ideal position for birth, and went out-of-network to a top-rated chiropractor in New York who specialized in something called the "Webster technique," a series of maneuvers supposed to flip head-up in vitro babies. I dissolved homeopathic remedies on my tongue, timing the number of minutes before I could have a sip of water without ruining the magic.
I hung upside down off the side of my bed with ice packs on my upper abdomen and music blaring near my pelvis.
None of it worked. Which meant, my doctor told me when I reached 35 weeks, that I would have to have an "elective" cesarean section, the delivery preference of most doctors.
Despite my efforts, I'd been aware of this possibility. And I'd done what any sane person with a medical conundrum and a Wi-Fi connection does—I'd scoured the internet for advice, protocol, and general sympathizing. Of course, looking for medical expertise on the internet is a bit like trying to get an accurate sense of your appearance in a funhouse mirror.
Nonetheless, I was able to get a basic sense of the risks. The primary challenge is that the head, which is the largest part of a baby's body, is more likely to get stuck during breech births than in head-down births, as a baby's bottom or legs are not always wide enough to pave the way. Other risks include cord prolapse, which is when the umbilical cord drops into the birth canal as the baby is moving out and gets squashed, cutting off oxygen—always critical, but more so when the baby's head comes out last. "All deliveries may have risks to both mother and child," says Karoline Puder, MD, chief of obstetric services at Detroit Medical Center Hutzel Women's Hospital, "but the risks of breech vaginal delivery...are those related to head entrapment. The delay may lead to the baby receiving less oxygen and having developmental problems as a result."
Overwhelmingly, my research and subsequent conversations with medical professionals left me with a sense of the complications. As one site admonished, even any risk is too great.
But C-sections are not a piece of cake. They come with their own risks, including higher maternal mortality, increased risk of respiratory distress for the baby, lower rates of breastfeeding, and even an increased rate of stillbirths for a second pregnancy. And having a C-section increases the likelihood of a C-section for subsequent pregnancies. "As with any surgery," the World Health Organization states, "cesarean section is associated with short- and long-term risks with potential implications in future pregnancies."
The rate of C-sections in the United States was 32.8 percent in 2011, well above the "ideal" rate of 10 to 15 percent, according to the World Health Organization.
I was also haunted by the fact that the rate of C-sections in the United States was 32.8 percent in 2011, well above the "ideal" rate of 10 to 15 percent, according to the World Health Organization. (This high rate has prompted the American College of Obstetricians [ACOG] and Gynecologists and the Society for Maternal-Fetal Medicine to call for measures to lower it.) And my reading also showed me that, if the right conditions are in place, breech births can be safe. Those conditions include: the baby in a favorable breech position (legs folded), the baby neither too large nor too small, and the mother's pelvis adequately sized. Head entrapment is a definite concern, but as Dr. Puder states, "this happens very infrequently."
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Given all this, I felt powerless and frustrated, forced into a procedure I didn't want. Informed choice felt like a kind of myth.
The standard practice for the delivery of breech babies derives from the improved safety of C-sections over the decades as well as a study known as the Term Breech Trial, which discovered in 2000 that breech babies born by cesarean had a better chance of survival than their birth-canal-traveling counterparts. The study was the largest randomized trial to date. The medical journal The Lancet, which published the findings, found the data so conclusive that it fast-tracked the study to publication. It prompted the ACOG to issue a statement in 2001 that said that "planned vaginal delivery of a term singleton breech may no longer be appropriate."
That study has since been criticized for numerous reasons. It was supposed to make sure that no baby's head was hyperextended (with the chin out, a baby is more likely to get caught on the pelvis), but it did not. It was supposed to limit the size of the babies, but many in the planned vaginal delivery cohort grew bigger than recommended. And the study did not account for the experience of the doctor nor the ability of the hospital to convert to a C-section if needed.
Today, in the United States, about 86 percent of all babies that are breech at term are delivered via C-section; in 1970, only about 15 percent of breech babies in the U.S. were born via C-section.
Two years after the study, the authors of the original research published a follow-up study showing that there was no difference in long-term outcomes between planned C-sections and planned vaginal delivery. But still, the Term Breech Trial prompted a sharp drop in vaginal breech deliveries worldwide. Countries like the Netherlands saw a decline from 76 to 40 percent. (In the United States, the decline was not as pronounced because C-section rates were already high—84.4 percent for breech presentation in 2001.)
In 2006, ACOG issued a revised statement. "The mode of delivery should depend on the experience of the health care provider," it read, and went on to say that "planned vaginal delivery of a term singleton breech fetus may be reasonable" under certain conditions. Yet, these days in the United States, about 86 percent of all babies that are breech at term are delivered via C-section. (About 3 to 4 percent of all pregnant women have babies who are in the breech position, according to ACOG.) Estimates vary, but in 1970, only about 15 percent of breech babies in the U.S. were born via C-section.
As with many medical practices, the health of the patient and the state of current research are only part of what goes into decision-making. As Elliot Berlin, a prenatal chiropractor and executive producer of Heads Up: The Disappearing Art of Vaginal Breech Delivery, points out,"a doctor's comfort zone is intervention. Cesareans are quick, the pay is better, and there is less liability." (Delivery costs vary widely, but average total cost for pregnancy and newborn care for a C-section was $50,000 in 2013 versus $30,000 for a vaginal delivery.) Dr. Leena Shankar Nathan, an OB-GYN and clinical professor at UCLA Health, echoed this sentiment: "If you have a defendable safer option, why wouldn't you choose it?" According to Stanford University Medical Network's Medical Malpractice Trend Review, in 2013 and 2014, more than $1 billion was awarded in medical malpractice cases with payouts of $5 million or more, "nearly twice the average of the previous four years." Though the number of malpractice cases has been declining since 2003, payouts are still high and birth injury cases are among the most common types of lawsuits.
The decline of breech birth delivery has also had the effect of contributing further to its decline. "Experience matters," says Max Kennerly, a lawyer in Philadelphia who specializes in birth malpractice. "You wouldn't put someone with a learner's permit in the Indy 500." Many doctors are no longer getting that experience because of the reduced rate of vaginal breech births. Teaching breech delivery varies according to medical school, and may schools include only videos, reading, and simulations in their training. As Dr. Puder points out, "the bias against vaginal breech delivery and patient preference for cesarean delivery limits the number of actual breech births that most residents in OB-GYN perform." Says Dr. Nathan: "I was trained in breech delivery, but I wouldn't feel comfortable doing it. And I think the same is true for a lot of my peers." It's a sad fact, says Dr. Puder, that this decline compounds upon itself: "Skills fall out of favor."
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All this makes sense: You wouldn't want a doctor who wasn't comfortable with their abilities attempting a complex and rare procedure, especially when there's an alternative. Still, this didn't use to be so rare—it's just that most of the people who worked in that time are going gray. But I found one.
On the Wednesday of my 37th week, 72 hours prior to having my baby, I left my OB's office in tears, having just been informed that she had scheduled the "elective" C-section for that coming Monday.
At the start of my pregnancy, I'd read articles detailing which questions to ask when interviewing an obstetrician and promptly ignored all of them. I felt too much like a student pretending to speak a foreign language than an informed woman taking hold of her health. I lobbed a couple of softballs about my doctor's schedule and called it a day. In reality, I chose my obstetrician because she was two blocks from my office and the waiting room had wood floors and some great Oriental carpets.
Nine months later, I regretted that inattention. But I had an option. Standing at the intersection of 55th Street and Seventh Avenue, in the middle of the Midtown lunch rush, I called the office of Dr. Gae Rodke.
I had found Dr. Rodke during one of my deep dives on the internet, listed on a chat board as one of a handful of doctors in New York who know how to deliver breech babies. She didn't take insurance, and the earliest appointment I could get when I first called a few weeks earlier was at the end of my 37th week. I had promptly scheduled the appointment at the time, but it was still two days away and I was afraid I was too late.
Could I go to an appointment Friday at 4 P.M. and still be able to cancel a Monday-morning C-section? That might at least let me know whether I was a viable candidate for breech delivery. If I wasn't, I could let it go and embrace my C-section as the necessary option.
She informed me that I had been traipsing around the city two centimeters dilated and she could feel my baby's bottom.
Late that Friday afternoon I reclined, feet in stirrups, gazing at the walls covered in happy baby photos and letters of thanks on Dr. Rodke's wall. She informed me that I had been traipsing around the city two centimeters dilated and she could feel my baby's bottom. As she explained to my husband and me after the exam, I was the ideal candidate for a breech birth—my baby was small and in a Frank breech position, meaning that he was folded in two, his butt at the bottom of my uterus and his head and feet at the top. The Frank position makes vaginal birth easier because the combined girth of a baby's back and legs is usually around the same size as the head. I also had the right size pelvis and was in good shape.
Now it was decision time. I waddled over to the nearest pizza shop, where I ordered a veggie slice. I knew the risks: the baby's head getting caught on the pelvis and cord prolapse. Dr. Rodke had recommended an epidural to mitigate the risks of my pelvis seizing on the baby's way out. And because I would be delivering in a hospital, the operating room would be ready if they ran into trouble. It felt like the right decision, but was I being crazy? The medical establishment, such as I'd experienced it, had basically told me to do the opposite.
The next morning I woke at 4 A.M. It was 10 days before my due date and also moving weekend, and my apartment was not U-Haul ready. I packed and cleaned the kitchen with an intensity that I wish I had had during the preceding weeks. As my husband left for soccer, I warned him that I had been feeling funny all morning. By noon, I had called my mother "just in case." Mid-afternoon at my new home, a mom friend who had come to help me unpack proclaimed that I "was definitely in labor." By 6 P.M. I told my husband that he was to come directly home after moving the last load of boxes and not to stop at P.C. Richard to buy a new toaster. And by 7 P.M. we were on the way to the hospital.
I made it to the labor and delivery floor of Mount Sinai West, the contractions coming fast and furious. I could feel an overwhelming urge to push. As the anesthesiologist got the epidural ready, Dr. Rodke kept her face an inch from mine, cradling my face in her hands, focusing my breathing, and making sure as hell that I did not let the baby out. As the effect of the epidural took hold, I was wheeled into the operating room, where the nurses tried frantically to remove my belly button ring in the event I needed a C-section. Then someone put an oxygen tube over my nose and commanded me to push. Several residents had piled into my delivery room as spectators of this rare event. My baby's back slid out. I squeezed every cell in my body.
At last, my baby's head emerged. I watched in a state of euphoria as he took his first breath and started crying.He was healthy and he was safe. The nurses placed my screaming bundle on my chest and as adrenaline-fueled words of welcome and joy spilled out of my mouth, my baby's cries subsided.
Any mother will tell you that pregnancy and delivery is a crapshoot, that the agonized-over birth plans are less "plan" and more "guide." In the end, we get what we get. But we are more likely to get an outcome we are comfortable with and understand, whether it's a planned C-section, an emergency C-section, or a breech delivery, if we are informed about our choices. For many of those breech mothers-to-be out there, there is a choice. As I discovered in subsequent conversations, many didn't know that breech delivery was an option and wished they had.
I am lucky that I can look back on the birth of my son with not only the joy that comes with bringing in a new life, but with the retroactive confidence that I did what was right for both of us. The months prior to his birth were a fog of confusion and uncertainty as my intuition clashed with conventional wisdom. During my pregnancy, I had coffee with a coworker who gave me some advice. "Mother's intuition is real," she told me. "Learn to trust yourself, even when it seems like the world is against you."
Courtney Doggart runs a non-profit based in New York City.