By Lizzie Johnson
Even before I became pregnant, I always knew I wanted to give birth at home. Home births seemed safe and familiar because my mother had me in her own bed thirty-four years ago. Moreover, hospitals had bad associations. Their wipe-down surfaces and windowless rooms reminded me of the months I’d spent being treated for breast cancer a decade earlier. A hospital birth was the last thing I wanted. And yet here I was, under the moonlight, my body bent double by contractions, climbing into the back of a car destined for St George’s hospital in Tooting. How had I got here?
The news that my baby was breech was delivered without much fanfare during a routine (but late) ultrasound at University College London Hospital (UCLH) in week 34 of my first pregnancy. At the time the sonographer was more concerned about a suspected and potentially dangerous complication to do with my umbilical cord, making my baby’s breech presentation seem almost incidental. Even after the doctors established that my umbilical cord was fine, I wasn’t concerned about my baby being breech. I had been breech until late in my mother’s pregnancy. She persuaded me to turn using moxibustion; a practice used in traditional Chinese medicine where dried mugwort is burned next to particular acupressure points. Plenty of time to turn, I thought. And there was always moxibustion to fall back on if my baby didn’t make its own way into a head down position.
Up until that ultrasound, my pregnancy had progressed without any real difficulties. It was deemed low risk and I hired a private midwife to help me give birth at home. I also registered with UCLH to have my antenatal scans and ensure that I could easily transfer into hospital if needed. My midwife seemed relaxed about the breech presentation, but suggested moxibustion and swimming to encourage the baby to turn. Each night before bed I ground up fresh ginger and put it into a plaster that I taped to the outside edge of my little toe. I got to grips with the exercises designed to encourage optimal foetal positioning on the Spinning Babies website, and could often be found lying on an ironing board propped against the seat of my sofa with my feet elevated in the air. Friends and acquaintances made suggestion after suggestion about how to turn breech babies. It seemed that everyone had a theory and a tale of a baby turned at the last minute. I was happy to give anything a go, no matter how peculiar, so long as it might prompt my baby to turn and keep my home birth on track.
Three weeks passed and despite my efforts the person growing inside me remained stubbornly bottom down. My midwife advised me against a homebirth if my baby stayed breech, and made an appointment for me to have an external cephalic version (ECV) at UCLH to try to turn the baby around. I knew the procedure came with risks, but on balance I thought they were worth taking if it meant I could potentially avoid a medicalised hospital birth. The talk of caesareans only began after two doctors failed to push the contents of my swollen belly into a more typical position. Responding to what they referred to as my baby’s “malpresentation”, the team at UCLH strongly encouraged me to opt for a planned caesarean section, arguing that a vaginal birth represented an increased risk to my baby. They could support a vaginal breech birth, and did agree to respect my wishes if I made this decision, however it was made clear that it would likely be a highly medicalised affair. I would have to give birth on the labour ward (the midwifery-led unit was not an option) and the delivery would likely involve obstetric interventions including lithotomy, and potentially forceps and episiotomy. An emergency caesarean might still be necessary if my labour wasn’t making sufficient progress, and I would have to agree to a caesarean if I had not gone into spontaneous labour by 40 weeks. Whether they intended it or not, I left UCLH with the feeling that I would be regarded as reckless were I to choose anything other than an ‘elective’ caesarean.
The problem, I later learned, was a scientific report published almost twenty years ago known as the Term Breech Trial (1). It concluded that an elective caesarean section presented a significantly safer mode of delivery for mothers and babies than planned vaginal breech births. Following the publication of the report vaginal breech births became a rarity in developed countries and a whole generation of doctors and midwives went through their professional careers with almost no clinical experience of this type of delivery. As I read more and more online articles, clinical guidelines and blogs about breech presentation, I discovered that they were rare, affecting only 3-4% of pregnancies at term, but not abnormal. I also learned that since its publication in 2000 the Term Breech Trial had been widely criticised and aspects of its findings found to be flawed (2). Vaginal breech births could be as safe as vaginal cephalic births so long as the supporting doctors and midwives were trained and experienced in this mode of delivery (3). This is the catch 22 situation familiar to all pregnant British women who discover their babies are breech. Vaginal breech deliveries are safe with experienced staff, yet the Term Breech Trial had all but eliminated that clinical experience.
The day after the ECV my tender stomach muscles needled my conscience about going through with the previous day’s potentially harmful procedure. Weary with guilt, I tried to make sense of my new situation. A caesarean represented a major surgery; a prospect coloured by my previous treatment for breast cancer. I was terrified of what I perceived as the loss of physical sovereignty that my past surgeries had entailed. Following my mastectomy, the slow dissolution of my surgical stitches had counted out the postoperative days, turned into weeks, in which my body was bruised and swollen. I knew all too well how flimsy the promise, “You’ll be up and about in no time”. Despite their obvious differences, I struggled to separate the idea of a caesarean from my mastectomy. Having a caesarean was the most sensible decision given the lack of vaginal breech experience at UCLH, but it also meant letting go of the idea that my birth could be an opportunity to heal; to regain trust in my body and its physiological processes.
The fragile belief that there was still time for my baby to turn was my only shield from my fear of a hospital birth. Foetal positioning exercises took up hours of my time each day. I listened to hypnobirthing audio tracks designed to encourage breech babies to move into a cephalic position. Instead of resting, I took almost daily trips across London, spending hundreds of pounds seeking help from chiropractors, osteopaths and acupuncturists.
Two weeks before my due date I had the good fortune to meet midwife turned acupuncturist Meredith Churchill. Meredith placed her needles in my skin with care. She suggested that my baby had been given every opportunity to turn and perhaps there was a good reason for it staying with its bottom lodged in my pelvis. If I wasn’t sure about the caesarean, she proposed, perhaps I should research whether there were any other London hospitals with staff experienced in breech vaginal deliveries. That way, if there was nowhere supportive of a vaginal breech birth, I might find it easier to accept the caesarean and focus on making the experience as meaningful as possible to me. Her suggestions recognised how important it is for women to feel that they have agency in the way they give birth. Referring to the psychoanalyst D. W. Winnicott’s theory of the ‘good enough’ mother, Meredith sensitively suggested that my experience of birth did not have to be perfect: it only had to be good enough. Buoyed by these words, I began to let go of the perfect home birth I had envisioned and wonder what my ‘good enough’ birth could look like.
After a few hours of searching online, I sent emails to mothers and midwives interested in physiological breech birth asking if they knew of any London hospitals experienced in this area. One of the people kind enough to respond was Dr Shawn Walker, Midwifery Lecturer at King’s College London, who directed me to the breech clinic run by Emma Spillane, Lead Midwife for the Carmen Birth Centre, at St George’s hospital, Tooting. On contacting Emma, I discovered that over the past few years the team at St George’s had been building confidence and clinical experience in physiological breech birth. In the thirty-ninth week of my pregnancy, my boyfriend and I met Emma, looked around the hospital and booked in with St George’s. St George’s had strict guidelines designed to minimise the risk to mothers and babies. I had to give birth on the labour ward, rather than in their friendly midwifery-led birth centre. If I had not gone into spontaneous labour before week 42, I could not be induced and a caesarean would be necessary. Finally, if my labour did not progress smoothly, I would have to have an emergency caesarean. Although its policies were broadly similar to those at UCLH, for me the difference between the two hospitals was that the team at St George’s made me feel my wish to attempt a physiological breech birth would be supported and respected. What I was being offered was a chance at a vaginal delivery: there were no guarantees. I knew that I might still end up having a caesarean, but if that happened I could be certain it would be the right decision at that point. After weeks of anguish and confusion I finally felt ready to have my baby.
A day after my due date, I returned home from a long, slow walk in the summer evening. My boyfriend had gone to a work event and I slumped on the sofa, glad to take the weight off my feet. Ten minutes into an episode of the Great British Bake Off, I felt a small rush of water flow between my legs. I jumped to my feet confused and thinking that I might have wet myself. More fluid trickled into my knickers and down my leg. It took me a few seconds to realise what was happening. This was it: my waters had broken. I called my boyfriend to tell him he probably ought to come home. I called my midwife to ask her to come to check on me. I called my mother to share my excitement.
I rushed around the flat, shoving my slippers and phone charger into the hospital bag, wiping down the kitchen surfaces and tidying away clutter. My boyfriend arrived back. We sat on the sofa chatting, giddy with excitement. When the midwife appeared she checked my amniotic fluid, told us all was well, to get some rest and to head to the hospital, where she would meet us, once I was experiencing three contractions in every ten-minute period. My first contraction came as she spoke; a tightening in my uterus like period pain. It was about 9pm and I had no idea how quickly things would progress. I got into bed with my boyfriend and tried to rest, but the tightenings were too distracting. With each tightening I felt the urge to jump out of bed, as though I could run away from the feeling now taking over my body. I repeatedly ran to the toilet, responding to an urge as though I wanted to poo. I’d fail to shit and climb back into bed. After about an hour of this back and forth between bed and toilet, I stopped returning to the bed, preferring to lie on the bathroom floor. The surges of energy consumed my body for short periods at a time. I found myself saying to my boyfriend, “This really hurts,” for some reason surprised by the intensity of the feeling. With each surge I’d jump to my feet as though I could outrun it, and then bend onto all fours moaning. Not once did it occur to me to ask for the TENS machine or the glass of wine I had planned to drink as an analgesia, and had so been looking forward to after nine months sober. The sensations consumed me.
By 11.30pm it was clear to me that if I did not head to the hospital there and then I would refuse to go at all. I had no idea how many contractions I was having over what period of time, but I knew I couldn’t face getting into a car if we left it any longer. The plan had always been to take a taxi, but now in the heat of the moment I had no confidence in my power not to puke, shit or leak amniotic fluid in the back seat of a cab. We decided that my boyfriend would drive us. Armed with a bucket and an incontinence pad, I climbed into the footwell of the backseat.
In the car I fumbled with my headphones, eventually managing to start the playlist I had put together. Focusing on the music between the surges and the speedbumps, I belted out familiar songs all the way from Kilburn to Tooting. The sensations and the music enclosed me so completely that I was shocked when the car stopped and my boyfriend told me we had arrived. The short walk from the carpark to the labour ward was punctuated by several contractions, with pitstops leaning over bike racks and railings, but eventually we made it. I hobbled through the ward’s double doors and immediately got onto all fours in the corridor. Everything in my body told me to stay low to the ground with my bum in the air. A midwife directed us towards a waiting room, but the idea that I could sit on a chair was preposterous. After five minutes on all fours in the corridor, I was moved to “somewhere more appropriate”, which turned out to be a triage room. It took some persuading to get me off the floor and onto the bed to be examined. The routine blood pressure test and internal exam seemed unnecessary to me when I was certain that what I needed was to be taken to my own room and left alone. I only agreed on the grounds that after this there would be no more routine exams. The midwife checked my dilation and went to fetch a more senior colleague who also examined me. I watched them realise what I already knew: my labour was well advanced.
The midwife led us to a small room with no bathroom. I requested that the lights be lowered and the resuscitation equipment pushed to one side. The blankets, fairy lights and pictures that I had so carefully selected to make my hospital room feel more homely remained untouched in my hospital bag. All I wanted was to kneel on the floor, leaning over a couple of pillows, and disappear back into the headphones’ cocoon. I hardly noticed when my private midwife arrived and various hospital staff came and went. Surges of pain ebbed through me with no clear beginning or ending. I found myself chanting as their intensity increased, sometimes Buddhist chants my mother had taught me, sometimes instructions like ‘relax, relax, relax, relax, relax, relax, relax,’. When the intensity slowed, I would tune into the music playing on my ipod, occasionally giggling at song lyrics. “Nothing’s gonna change my world,” sang John Lennon, as my world was in the process of changing forever. The surges rose up regularly and relentlessly, crashing over my body. There was only one occasion during the labour when I integrated the contraction into my being, instead of trying to escape it. I rode the feeling, rising to meet it with my breath. It was my only glimpse of how labour could be experienced without feeling pain in its usual sense.
The surges continued and I was starting to get tired. I wriggled around on the floor searching for a position where I could rest a little. But as I lay on my side I had the sense that it was a mistake to try to slow the surges’ intensity. It seemed that any momentary relief would merely slow the juggernaut of labour. There was no way out but through.
My midwife suggested I stood and leaned over the bed, swaying my hips from side to side. I managed this until the next surge propelled me to climb onto the bed, where I would stay, on all fours, for the rest of the labour. My birth plan specified that I should not be offered pain relief and I was so overwhelmed by sensation that the idea didn’t enter my mind. What I did do was tell my boyfriend that I didn’t think I could do it. “You’re doing it,” he replied. I gained strength from knowing he was at my side throughout it all; holding my hand, rubbing my shoulders, encouraging me to relax my clenched jaw and making sure I kept drinking water. Seeing that I was flagging, my private midwife waited until the hospital midwife had left the room and encouraged me to eat. (Eating is generally discouraged in hospital because it increases the risk of complications should a labouring woman go on to need a general anaesthetic.) Instead of eating, I slurped a carton of apple juice and felt replenished by the sugar.
Every so often I would surface from the pure sensation of the surges and become aware of the people around me. I turned to my hospital midwife, who had already cared for me for over an hour, and said “Hello”, as if introducing myself for the first time. This represented a rare occasion during labour where my feelings towards her were not warped by circumstance. I hated her when she did her initial internal exams; when she explained that she needed a small lamp light in the room so she could see to write her notes; when she held the Doppler to my belly to check the heartbeat of my baby at ten-minute intervals. I also developed a passionate dislike for the objectively personable man who was the Consultant on duty. Although I was well aware of the risks associated with a vaginal breech delivery, he insisted that I remove my headphones so he could explain again and warn me about the possibility I might need a caesarean. “Just say what you’ve got to say quickly and I’ll consent,” I murmured; prepared to say anything so he’d go away.
The labour drove on and my hips began to feel as though they were about to burst from the pressure. Then, when the baby’s body started lowering into the birth canal the sensation changed completely. Still on my knees, I gripped the metal bed head and emitted a low, fast “Huh!”, like the sound made by someone doing martial arts. I felt prised apart and as though I couldn’t breathe. As the surge subsided I could feel my baby’s body slowly slide back up into my body. “Huh!”: the sensation of my baby’s body moving down again. I felt it slide back inside me. “Huh!”. “Huh!”. “Huh!”. The surges pulsed the baby’s body in and out, until it began to move down and stay down. “Huh!”. Somehow my headphones had been removed. I was kneeling on the bed facing the wall, unaware of the crowd of people gathered behind me. “Huuuhhh!”: I felt my body opening. At this point, my boyfriend would recount later, a tiny bottom emerged from my backside and did a swirling shit of treacle-black meconium. Another surge came and I went with the feeling, experiencing relief as a leg flopped down out of my vagina, then another. A downwards movement forced my body open and out slipped the arms. The baby was now out up to the chin and the surge subsided. “You need to push now,” said the midwife. “But I don’t feel the push feeling,” I replied. The directions issued by my body had got me this far and I was unwilling to listen to advice that ignored my instincts. But the medical team now gathered in the room explained that getting the baby out quickly was now imperative, so I forced myself to push like I was doing a shit.
I felt a tremendous rush of relief as my baby slipped fully from my flesh. I spun around and there on the end of the bed lay a lanky purple doll on its back. The Consultant rushed towards the silent, still baby to cut the cord. My boyfriend tried to stop him, hoping we could still achieve the delayed cord clamping set out in our birth plan. But our baby still hadn’t drawn a breath, and a medical chorus insisted that cutting the cord now was necessary. We consented quickly, the Consultant cut the cord and our baby yelped and opened its eyes. Everyone in the room cried out and sighed with joy. My baby looked so utterly unfamiliar, like a person I had never seen before. A paediatrician I hadn’t noticed until that moment whisked the baby over to the resuscitation equipment to perform some initial checks. “What kind of baby is it?” I asked my boyfriend. “It’s a girl,” he replied. It was 4.20am. I had been in the hospital for barely four hours. My baby weighed 7lbs and 3oz. Five minutes after her birth her Apgar score was 10. I had a small perineal tear, but apart from the stitches that sewed it up I had managed to avoid any intervention. We had made it. She was safe. She was well. So was I. I felt elated.
My daughter was not born at home surrounded by the sights, smells and people now familiar to her, as I had hoped. She was born in a room filled with wipe-down surfaces, strangers and her parents. Her birth was not what I had imagined. But it was good enough.
1) Hannah, M, et al. (2000) ‘Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial’. The Lancet, vol. 356, issue 9239, pp.1375-1383.
2) Glezerman, M. (2006) ‘Five years to the term breech trial: the rise and fall of a randomized controlled trial.’ American Journal of Obstetrics and Gynecology, vol. 194, 1, pp.20-25.
3) Royal College of Obstetricians & Gynaecologists (2017) Management of Breech Presentation (Greentop Guideline No. 20b).