Episode 123 - Vaginal Breech or Caesarean with Dr Rixa Freeze
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast. If you love this podcast and use it all the time for your clients, or you've been consuming episodes to get prepared for your birth or your own clinical journey, consider becoming a premium podcast member for only $9 a month. This helps me to commit time and energy to creating podcast episodes in place of my other paid work. So please do consider contributing a small investment of $9 a month in support of this podcast. See the show notes below for the link on how to join. Today, I'm joined by Dr. Rixa Freese, who among many things is the president of Breach Without Borders. She's also a mom of four, a researcher, and actually my first experience of Rixa's work was in 2010 when I read your PhD, which is called Born Free. And you looked at unassisted birth and I was actually struck by how brilliant a writer and researcher you were.
Mel:
[1:25] The attention that you gave to the research process was so meticulous and I still now, my lasting memory of your thesis was how exceptionally written and executed it was. It was by far the best piece of academic writing that still today I've read on the topic of free birth and it inspired my own PhD which is birthing outside the system but our topic for today we've invited Rixa to talk about breach, breach research and breach without borders which was founded in 2018. It's a not-for-profit organization dedicated to breach training, education, advocacy and you guys help translate information across all kinds of borders not just countries and languages but also educational and academic borders. Welcome, Riksa.
Rixa:
[2:19] Thank you. I'm super excited to be here.
Mel:
[2:23] Did I miss anything in your introduction?
Rixa:
[2:26] No, I think that's good. I think it's also important for people to know that all four kids of mine were born at home. My first was unassisted on purpose and my third was unassisted not on purpose because the midwife didn't take me seriously when I told her to come. So that's my birthing history. And it's just important as the background. That's kind of my, I suppose you could say it's my bias and a little bit of where I come from personally. So I love home birth. I love unassisted birth and that's kind of how I grew up in birth.
Mel:
[2:56] Yes. And just also so people know, you're not trained as a midwife or a maternity care provider in any way.
Rixa:
[3:03] I'm not a clinician. I did apprentice and kind of shadow some home birth midwives for a couple of years when I was doing my PhD. So I kind of did the beginning stages of apprenticeship with them. I actually played around with the idea of going into midwifery as well, but I was busy getting my PhD done and I was starting to have children during my PhD years. And I just wasn't a good time to try to go into midwifery, especially the US based midwifery, which was illegal in most of the states I lived in. So, yeah, I'm not a clinician, but I do have a background in birth that's more than the average person's, I would say, having attended quite a bit of home births and shadowed some midwives for a while.
Mel:
[3:41] I'm also curious as to what motivated you to choose midwives for your last three births and not your first.
Rixa:
[3:51] Yeah, usually it goes the other direction. Typically, you know, women tend to have... Not always, but a disappointing birth in some way, maybe some trauma. And then maybe they'll move from hospital to home and then they'll have a couple home births and they'll move to a free birth. You know, it typically more typically goes that direction, but I'm a little unusual. I do things my own way. I was immersed in the world of home birth and midwives during my PhD years. And then, you know, I think I would have had a midwife with my first, had the midwife that I was shadowing and going to births with. Had we still lived in the same state, we had ended up moving out of state for my husband's first job while I was finishing my PhD. So part of it was just the lack of a midwife that I felt really personally connected to, even though I was shadowing another one. She was lovely, just didn't want her for my midwife. And part of it was because I was doing my research about unassisted or free birth, I was also immersed in those stories. And I just felt so drawn to it that first time. And I didn't feel drawn to it in the same way the other times. And I had to kind of respect that, which was a really intuitive, non-rational way of making a decision both to decide to have a free birth the first time and then the other times just respecting this feeling. I just did my best to honor what felt right at that time and found a fantastic midwife who was more than thrilled to be completely hands-off. And besides listening to the baby's heart tones, I told her, just let me do everything myself. I'll let you if I need any help. And she said, that's my favorite kind of birth. And I said, you're hired. It's just perfect.
Mel:
[5:20] I love that you didn't cling to an ideology over your own intuitive feeling around that what are you currently doing as your main paid work at the moment.
Rixa:
[5:32] Breach Without Borders takes full time and more. Yeah, so that's all I'm doing right now is breach. I have a lot of hats as the president of the organization since we're still quite small. So, you know, I run everything in the sense of keeping these going, supervising, overseeing, do the finances, the bookkeeping, the accounting, graphic design, web design, all the video editing, all the content creation, curriculum development, you know, translation, overseeing, book producing, editing, graphic design for the book, you know, writing a lot of the books. So I kind of have many hats depending on what needs to be done on which day. So it keeps me busy. And of course, I try to keep up on the research, but that's what I do is everything breech.
Mel:
[6:14] Yeah. Okay. Amazing. All right. Well, let's get into the questions because we're here to talk about breech research among other things. So I wondered if we could first start by if you could describe the current circumstances or situation around vaginal breech birth around the world?
Rixa:
[6:31] Generally, it's an art that has gone extinct or is near extinction. It's an endangered species around the world where it hasn't completely died out. That's the nicest way of putting it, I suppose. We had this Catch-22 situation when cesarean section became safer in the mid-1950s, give or take, with the new techniques of a low transverse incision. And of course, then we had antibiotics developed, you know, in those couple decades. So that operation became a lot safer. And breach was the first major indication that cesarean section became used for on a massive scale, almost right away, starting in the late 1950s. I traced it back to then. And for any other obstetrical indication or circumstance, breach was the very first to have a massive rise in cesarean section. Pre-research, it just happened kind of somewhat organically, but somewhat because that people were starting to publish as early as the late 1950s that we should be doing cesarean sections for every breach presentation. So it was pushed through without...
Rixa:
[7:36] Much study without looking at long-term consequences. And more and more, even before the big study in the year 2000, we had this kind of feedback loop where people started going more and more to surgery as the solution. And as they did that, they didn't have as much experience. And because they were not as experienced, it would accelerate the move to surgery even more and more because they were losing their skills. So we have a massive loss of skill of skills within like one or two generations of midwives and obstetricians, which wasn't complete, but it was still pretty significant over those three or four decades. So from like early 1960s to the year 2000 before the one really influential study was published. So that's what, you know, about four decades. And in that time, you know, a couple of generations of healthcare providers, it went from being almost always vaginal to almost never, even prior to the term breach trial.
Rixa:
[8:38] So it was, you know, kind of an organic thing that happened and it didn't happen uniformly in some countries who had a pretty high vaginal birth rate still. So there was still a wide amount of variation, but in general, in the more, the richer countries, the general trend was going towards cesarean section and some, some much higher than others up until we hit about the year 2000. And that, of course, then brings in the term breach trial, which, you know, I think we talk about it too much, honestly. I mean, it's one study that was done almost 25 years ago, and we've had so much research since and so much research before. And, you know, it still dominates the discussion, unfortunately, but we have to talk about it because people still refer to it and think that that's the last word.
Mel:
[9:24] Let's do it because I know everybody talks about the term breach trial. I think, though, because it gave many clinicians such permission to continue with what they were already doing, and it's also the study that is quoted back to women as to why they should choose a cesarean section. This is what sometimes their clinician will suggest and recommend a cesarean section, and they'll use this term breach trial as the justification. So can you give us a brief rundown for people who are just coming to this and breach is new and trying to understand what their clinician is talking about with the term breach trial? And we know that the term breach trial wasn't the reason that we do cesarean sections for the majority of breaches, but it became a convenient tool to continue doing it that way.
Rixa:
[10:19] Yeah. Yes, you're absolutely right. It didn't start the trend. It cemented the trend, which was already mostly in place. And like you said, it gave people permission to basically stop doing vaginal breach birth because they were mostly stopping it. it was already on the way down. If you look at the extinction curve, we were near the end of it already before. So why is the term breech trial so important?
Rixa:
[10:42] Well, in medicine and obstetrics, we have this golden ideal that if you do a randomized controlled trial, it's somehow better than just studying an observational study where you just look at what's happening on the ground without randomizing groups of women into two different care paths. So supposedly, and there's really good reason for this, especially when you're looking at like a drug that's being introduced, you randomize and you double blind people if you can, you know, half of you get one thing, half of you get the placebo, randomly assign those two people to the groups, you see what happens, right? For something that's very simple, you can actually get a lot of confidence of if something is effective or not. And so this idea of valuing a randomized controlled trial over just observational data led to someone saying, hey, we should randomly assign women to have a C-section versus a vaginal breech birth when they have a term breech baby. And finally, we can settle this pesky question of, should we do vaginal breech births at all, or should we just do surgery for everybody? So it was done with good intentions, but it had a lot of consequences. And I don't think that the study authors themselves would have necessarily wanted that to be so. So the study was done and published in the year 2000, and it had about 2,000 women total in the group. So about 1,000 women in each group were randomly assigned to have a vaginal birth or to have a C-section. So already there's
Rixa:
[12:11] Listen to this. So most women aren't okay being randomized to having a surgery versus a vaginal birth on the toss of a coin, essentially. Most women have a preference. So this was a very narrow subset of women they had to be able to recruit and ask if they'd be willing to participate.
Rixa:
[12:26] Okay, so first off, that already, I think, really limits the applicability of the study. It's only women who, I hate to put it this way, but they didn't care either way. Not that they didn't care about their baby or their birth, but honestly, it didn't really matter to them either way that they would be okay. Just having someone else say, yeah, I'll give you a cesarean, you get a vaginal birth, right? So they were able to recruit these 2000 women in about 125 or 26 centers around the world, some in high resource countries, some in low resource countries. So it was fairly heterogeneous study. You know, it wasn't all in one center, but it was all around the world. Okay. So 1000 women in each group, more or less, let's see what happens. Well, when they looked at the the data, they did find a lot higher rate of mortality and morbidity, which means injury to the baby among the vaginal group than among the C-section group. And when I say a lot higher, it's statistically significant, although in absolute numbers, it's still fairly small. So the neonatal mortality rate for the vaginal birth group was about 13 per 1,000 versus three per 1,000 for the planned cesarean section group. And then there's also a rate of neonatal injury, and it was significantly higher when we talk about statistics among the vaginal birth group than the cesarean group so are
Mel:
[13:42] It true that they stopped the study early when they saw these stats.
Rixa:
[13:46] They yeah i think they did yes um they were going to have more people but they thought they saw the statistics and said it's pretty clear that it's significantly different we're going to stop it and just publish as is because they saw a trend that was it's pretty strong in this study right
Rixa:
[14:02] And so because this one study found, you know, 13 per 1,000 versus 3 per 1,000 for neonatal mortality and similarly higher rate for morbidity, which is injury again to the baby, mostly short term, they published the recommendation that all term breech babies should be born via cesarean section. And because this was a randomized controlled trial, it wasn't just looking at what was already happening, you know, but it was actually actively randomizing women to one or one of the other care paths. It's considered a stronger study than even a study with a lot larger numbers because of it being an RCT or randomized controlled trial. So it had a lot of weight in the obstetric community.
Rixa:
[14:42] So not surprisingly, around the world, it spelled the death knell for vaginal breach birth. I mean, and we had almost immediate uptake of the recommendations, which means that vaginal breach birth, which was already a dying art in many places, died or almost died. There was still, you know, the occasional rebel holding out, you know, hiding in their dugout and doing it here and there, but mostly it died, especially in any place that had access to surgery. And we're not just talking about resource-rich countries, we're talking about, you know, places that have otherwise don't do a lot of cesarean sections because it's still too dangerous for the mother, you know, like in Tanzania, for example, they're doing 80% cesarean sections in a hospital versus it was, you know, maybe 20% before the term breach trials. So it really made a big difference around the world.
Mel:
[15:33] And in terms of such rapid uptake, that speaks also to the preference of the clinicians, that a study floated to the top that really represented what they actually wanted to keep doing, and so they grabbed it. Because then when there's other research that comes out, for example, that talks about the amazing success of midwifery care and reducing birth and all these things, that gets buried because that's inconvenient and it doesn't suit the current system structure. So I'm not surprised, you know, that this was an appreciated study. It really said what they wanted it to say. Yeah, precisely.
Rixa:
[16:18] I mean, let's talk about, you know, episiotomy, you know, which is when you cut the vagina open with scissors. Most of you cringe if you hear that. You should cringe because it's a non-evidence-based intervention that a male made up in the early 1900s without any research. It was widely adopted by most obstetricians and a good number of midwives in some countries. We had decades of really good research showing that it was an absolutely harmful intervention with really no benefit. It shouldn't be done. And it took decades to get rid of the practice despite multiple randomized controlled trials. So yes, absolutely. We had a cultural bias. People wanted cesarean suction to be the answer. And that's why in a number of two months, we had some countries going from a 50 cesarean rate to 80 in two months right it's absolutely about obstetric bias and what they wanted to hear because i can guarantee you if this study had found that vaginal birth was equivalent or even better we would still have a rising cesarean section rate right it just would have been ignored yes
Mel:
[17:14] I believe it i believe it and here in australia actually we still have a 25 percent episiotomy rate despite I know it's scandalous it's criminal um so the term breach trial, We see 13 in 1,000 babies compared to 3 in 1,000 babies for mortality with vaginal breach versus cesarean. Do you have some theories on why the numbers looked like that?
Rixa:
[17:51] So Marek Glazerman, who's an Israeli obstetrician, analyzed all the cases of death. He got the records for all 16 cases. There was about 13 and three because there was about 1,000 people in each group. And he looked at the records of what actually happened. And he published this six years after the Turnbreach trial and concluded that very few, if any, of the cases of neonatal mortality in either group were related to mode of birth. And we also found that there were a number of cases included in these perinatal deaths that shouldn't have actually been included in the study. We had a couple of cases of twins where they were not supposed to be twins. We had some cases of very, very tiny fetuses. We had some cases of neonatal or congenital anomalies, which were supposed to be excluded. We had some cephalic babies in the death group. I mean, it was so messy when you actually look at this. And I don't want to, I'm not laughing because of these babies' deaths, but it was absolutely a mess. When you look at the actual cases of these deaths, there were so many that should not have even had made it into the study. So that muddies the water incredibly.
Mel:
[18:59] Yeah.
Rixa:
[19:00] And there's also complicating factors that, for example, I think around 20% of the vaginal breech births had no experienced clinician present. Can you imagine if 20% of cesareans were done by somebody who didn't have any experience, right?
Mel:
[19:18] So we're not comparing equivalent groups.
Rixa:
[19:21] Right?
Mel:
[19:22] Exactly. So we got up to in the term breach trial. So, so far, 1,000 women in each group. We've got higher risk of mortality and morbidity in the vaginal breach group. We discovered that actually those numbers are quite muddy, that there were some twins in there that were supposed to be excluded. There were some head down babies included in the breach deaths and actually the interesting part as well of this trial is that it was done in multiple locations which although in some ways is good because it increases the generalizability of the findings it's also very hard to standardize a randomized control trial when you have all those different sites meaning that the management of breech births could have been different at all the sites and it could have been individual or specific sites that had far worse outcomes than potentially more expert sites.
Rixa:
[20:27] We see around the world there's such a huge variety of techniques. I mean there are certain things that are kind of global like most people have heard of the MSV technique you know it's the it's a technique to flex the head but you know some countries do loves it some countries do Bracht, some countries do Berns Marshall. So it, you know, the technique varies by geographic region, and they do these techniques. And then the UK will have these techniques, which sometimes goes to the UK colonies. But then like, you know, central, you know, like Germany and Europe will have different ones.
Mel:
[20:54] So are there any countries who were doing amazing in the area of breach?
Rixa:
[21:00] Well, yeah. And actually, there is a really important follow-up study to the term breach trial done out of France and Belgium in 2006. It's called the PREMOTA study. Because in France and Belgium, they had always maintained their skill set. They didn't abandon it after the term breach trial, like some countries did. And even to this day, it's normal for every obstetrician coming out of residency to be well-trained in a vaginal breach birth. It's kind of seen as a normal thing to do. And because of that, they said, let's do a nationwide study of what's going on happening in the ground in our countries where we still feel like we have good skill and technique. It's very medicalized. So it's on the back with an epidural, you know, it's supine, but they're good at what they do. And they indeed, they did a large study with about 8000 women. They were not randomizing. So this was actually more reflective of what happens in real life where women in consultation with their midwives and their doctors choose what they feel is the best route. So some are choosing vaginal breach birth, some are choosing cesarean section instead of being randomly assigned. But they found that there was no significant difference at all in perinatal mortality or in neonatal injury, even in the very short term, where sometimes you can expect a slightly higher rate of short term injury, for example, with a vaginal birth, which usually tends to be transitory and disappears. Another really important country was Norway.
Rixa:
[22:19] And Norway was very hesitant to uptake the findings of the Turbreech trial. So they did a really careful study a couple of years after it was published. And they looked at their own national data. And then they also did a big systematic review of all the other evidence out there. And their own national data found that the rate of neonatal mortality was very low and almost identical between cesarean section and vaginal breach. I think it was 0.6 versus 1.2 per 1,000. So we're talking the Turbreech trial is 3 in 13. And when they looked at their groups, they're really small and very close together. And, you know, one was slightly higher, which might not even reach statistical significance. So they said, as a country, this is a skill that we've always taught. This is something that's seen as normal and safe to do. And our results are excellent. We're not going to move to cesarean section. And so as a culture and a country, they kept that skill set alive, you know, very deliberately so as an obstetric decision. And to this day, it's still seen as very normal to have a vaginal breech birth in Norway, and they have excellent results.
Mel:
[23:20] This makes me realise too that outcomes aren't attached to the breech position. I actually believe that vaginal breech outcomes are more indicative of the care given to a woman rather than the inherent danger with breech births. And although I don't like to talk about the risk of breech birth, women are being encouraged to make decisions about breech birth based on the assumption that it is more risky to have a vaginal breech birth this is what they're probably told by their care provider particularly here in australia where we are understood so can you speak to the actual what we know about the the possible risks of vaginal breech births in comparison to cesarean the short-term ones, because I realized there are some long-term risks to both of these options. The idea of this podcast as well is that women would be able to hear this information and make a decision for their own breech birth potentially. So what do we currently know about the risks of vaginal breech compared to cesarean section?
Rixa:
[24:38] Yeah, if we take a look at the research and conglomerate as many of the big numbers as we So that's called doing a systematic review and meta-analysis, if you want to get into the technical terms. We can come up with some kind of good estimated numbers that are reflective of what's realistic in a resource-rich setting, right? And, you know, in a setting that in some places are skilled and some places are less skilled.
Rixa:
[25:06] So generally speaking, we can pull some numbers out and give some estimates. So for example, the ARCOG, which is the UK Obstetrics Association, estimates that about one in every 2,000 babies that's born by planned cesarean section will still die because there's a certain baseline level of death that just happens. It's just part of being pregnant and having a baby, but that's kind of the baseline risk of the planned cesarean section at 39 weeks. So you're cutting off a few weeks of pregnancy. you're cutting off all the events that can happen during labor. In comparison, if you have a head down baby and you plan on having a vaginal birth and you have a vaginal birth, about one in 1000 will die. Okay. And that's the risk that then is it, that's kind of the assumed risk that most people are still very okay with, because that's what most women still plan today is if they have a head down baby, they'd plan to have it vaginally. Thankfully we're not doing cesarean sections for everybody yet. But, Okay, so we have those two baseline risks, one in 2000 for planned cesarean section, one in 1000 for a normal head down vaginal birth. And the numbers seem to suggest that in a kind of a global context, global, but still, you know, for resource rich country, right? Maybe it's about one in 500 with the vaginal breech birth. So there is a slightly elevated risk.
Rixa:
[26:26] So about half of that is inherent in just being pregnant, waiting for labor and going into labor. So regardless of presentation, there's just, you know, it's about one in 1,000 of that is that risk. And the other one in 1,000 that adds up together to be one in 500 is something with the breach. Okay. And it could be lack of provider experience. It could just be that sometimes breaches do really weird things because they have all these limbs that can kind of get folded up and stuck and, you know, and don't come out and you have to know how to get them out correctly. So I think that's a good global kind of estimate in terms of big numbers, you know, averaging a lot of countries, a lot of range of experiences today.
Rixa:
[27:04] That's a pretty reasonable estimate. Canada has done its own estimate. It's somewhere in that same neighborhood. We have a lot of really big meta-analysis from a number of other countries. You know, the outcomes are better in France and Belgium, right? That going back to the PREMOTA study, they're probably better in Norway than that global estimate. But that's a probably pretty reasonable number. But, you know, we... It's really difficult because you could go to a hospital and have an obstetrician who's never done a singleton normal vaginal breach. Is that safe? Honestly, I don't know. And that's the real issue. It can be very safe. We're seeing that it can be as safe as a planned cesarean section in certain countries where people have a good level of skill. But is it going to be safe for you to have someone who's frightened and panicked and doesn't know what to do and has never learned it that's a really different issue right and that's where we're stuck right now
Mel:
[28:06] Yes i have to agree and this is what my thoughts are and how hard it is to counsel women about breech birth is, to to let them know these stats that you just mentioned you know one in 500 if they're planning a vaginal breech birth and one in 1,000 if they're planning a cesarean breech birth. However, they may inadvertently be in more danger if they're presented with a clinician who's frightened of breech birth and who doesn't know what they're doing. I've done breech training and I can see how easily somebody who's frightened and inexperienced could really damage a baby independent of the fact that it's breech and my question I always ask myself and invite women to ask themselves is is it more dangerous to have a vaginal breech birth with an inexperienced clinician or to have a cesarean section with an experienced clinician who knows how to do cesarean sections yeah.
Rixa:
[29:14] And that's that's so tough because because, Yeah, it probably is going to be more dangerous if that clinician doesn't know what they're doing. They probably have done a thousand or more cesarean sections. It's just routine. And there aren't as many surprises as there might be with a breech birth. I don't know. Never done cesarean sections, so I can't speak personally. But it's a pretty standard procedure. You know, it's kind of you've done a couple. You've done most of them short of, you know, a really unusual situation. But although I suppose we could say the same with breech. Most of the time, the breech babies just come out. You don't do anything. And then there's the rare cases where they do spectacularly weird things. And they get stuck in all sorts of strange ways. And you have to really understand the pelvis and the baby and how you can get the baby out safely and work its arms and its legs out in the correct fashion. So yeah, that's the issue we're facing now is how do we get out of this catch-22 where we're stuck in this negative feedback loop of not enough skill, not enough training, not enough experience?
Rixa:
[30:13] Somebody has to be brave enough to say, I'm going to start doing it anyway, and I'm going to start getting retrained. Because if we don't, we're just going to be stuck in this horrible situation. And we probably will have more losses with a vaginal breech birth than we would like to see because people don't know what they're doing. But it's a situation that would be a little feisty now. We should not be in. And it's a total nightmare. And it's a tragedy that we've let ourselves lose our skills to the point that an obstetrician or a midwife who is supposed to be able to do birth, that's their entire job, has no idea what to do 4% of the time. Because 4% of babies are breech at terms. Half of all twins have at least one breech presentation, almost half. So that's a lot of breeches. Honestly, it's not that rare of an occurrence. And they have no idea what to do besides surgery. You could you imagine saying well we're just gonna you know every other physician or one out of 10 physicians we're just gonna have them come on the floor and they won't know how to do a cesarean section no matter if you need it you know too bad shrug that's what they're doing to breach like could you imagine every every second tuesday no cesarean sections you know too bad you know it's just completely yeah yeah
Mel:
[31:29] The thing i can pour it to is imagine if for example we were no longer taught how to manage a shoulder dystocia uh in birth you know you could very easily be presented with a surprise breach and need to need to help that baby in the same way as any moment a baby could have a shoulder dystocia and it has to be within your skill set to be able to manage shoulder dystocias whether you're expecting it or not and yeah as you said our one job is to help women who are pregnant and having a baby and then we've actively chosen to de-skill in one particular area and expect women to be okay with it what I love about the de-skilling here though is, is that obstetricians don't seem interested in re-skilling, at least here in Australia. There's a small rebellious portion. What I love is that midwives are super keen, and so what I can see is a transference of this skill out of the obstetric realm, which is where it has been for us here in Western countries, and back into the midwifery realm.
Rixa:
[32:44] Yeah, it absolutely should go back into the hands of midwives because you don't need to be a surgeon to do a vaginal breach birth. You just need your hands and reasonably decent brain. I was talking with Andrew Bissitz. We were together in Hungary for some breech trainings. And he said, I think the future of breech needs to be in the hands of midwives. Midwives need to run the breech services and the breech clinics and the hospitals. They're the ones who actually want to do it. And our lovely obstetricians, they can just do the surgeries when they're needed. But we don't need the obstetricians. They're frightened of it. They generally don't want to do it anyway. So let's, I totally agree. The midwives need to be running and starting breech services. And we just have our lovely OBs as backup when they need surgery. I just think it's a perfect win-win. People who are keen do it. And the people who aren't, well, they can just continue doing the surgeries when they're needed.
Mel:
[33:38] Yeah. So this is the upside that I can see to obstetricians intentionally de-skilling is that now we get to claim breech birth back into the midwifery realm. The other thing I want to highlight is that a breech birth is different to a breech extraction and, And so there can be many ways of attending a breech birth, and some clinicians, if they're presented with a breech baby, will always physically extract the baby with some assistance. Whereas what I understand with breech without borders, and, you know, I've done Dr. Stu Fishbein came to the Convergence of Rebellious Midwives this year in Sydney and did his reteach breech course. And you know theoretically just like any other head down baby you just let the breach come and if it doesn't you diagnose why it isn't coming and then you can do techniques to to help the baby out in your understanding how many babies are going to need to be extracted manually with with those techniques and how many would just happily be born on their own.
Rixa:
[34:51] It varies by provider, okay? Some providers have a higher rate of hands-on assistance, but with a physiologic breach, so that's when the mother is moving, she's choosing the positions that she feels best, she's probably non-anesthetized, or if she has an epidural, she has a good walking epidural with mobility and movement and sensation. So that's, yeah, that's our approach. And so with that approach where you're really following the mother's lead. She's really following her body, probably in some form of an upright position, most likely. We're not prescriptive about it, but we encourage...
Rixa:
[35:25] With that approach, even most of the maneuvers that you do, it's usually pretty minor. I mean, by far the most common assistance is called a shoulder press when everything but the head is out and you press backwards on the baby's chest with one or two hands. That helps the head tuck and flex and come out. And, you know, it's a pretty minor intervention. So even if you're assisting, much of the assistance is fairly minor. And then more rarely, there's, you know, more major assistance where you have to like reach in and bring an arm down. I'm doing this in the camera, but you can't see him sweeping my arms down. And sometimes you have to go and do some bigger maneuvers where you have to push the baby back in and rotate it a little bit to get it unstuck. Right.
Rixa:
[36:03] But so some might have, you know, 50 percent rate of assistance. Again, most of which might be a shoulder press. Some might have, you know, only a 20 percent rate of assistance. But still, the majority, especially in terms of large, big maneuvers, is still pretty rare. Right. If you have a physiologic breach that really big maneuvers, really difficult births, it's pretty rare to have to need to do. something. It's just as hard to say an exact number because it does vary widely between practitioner. Those who are really experienced in physiologic breach and have a clientele who are very motivated and who use maternal movement find that almost all of their interventions, if we can even say that, is just maternal movement and positioning alone. And there was one highly skilled midwife that we worked with until she died a few years ago who had done well over 500 breaches and about 500 sets of twins. And she said towards the end of her career, she only had a 3% transport rate for her breaches and 90% of her interventions, quote unquote, were just position changes alone. She rarely had to put her hands in and do something. So
Rixa:
[37:02] It's really important to realize that, yes, if you have a traditional vaginal breech birth, the way that obstetricians were trained for centuries, which is on the back, highly anesthetized, usually doing some kind of manipulation on the baby once it's out to the chest or to the waist, that is a really different process than a physiologic approach where the mother is active. And it's really the dance between the mother and the baby to try to work their way out. And we know from several sets of research that it's a lot safer to have a physiologic breech birth than a breech birth on the back. I mean, safer for the baby, less injury for the baby, less injury for the mother. You know, it's faster, much fewer maneuvers and a much higher rate of a successful vaginal breech birth rather than moving to cesarean section. So, you know,
Rixa:
[37:50] All breech births are not made equal, right? There's some techniques that are a lot more likely to lead to success. And that's another reason why midwives should be doing the breech births in hospital and out of hospital. But midwives need to lead the breech birth clinics, the movement to form specialty clinics, because midwives are the experts in doing these physiologic births. Generally, they know a lot more than obstetricians how to support physiologic labors, how to use maternal movement and positioning. It's just what they're trained to do. I'm not saying that no obstetricians can of course you know there's a range but generally midwives are the ones who are doing them and understand that and they can take that skill set and directly apply it to breech births so they're the ones who should do it because it's going to be more successful that way yeah
Mel:
[38:33] And a lot of women are encouraged you know if they do manage to find a clinician who will attend a breech birth they're often encouraged to do it with an epidural and And there's all these requirements from the obstetrician. Yes, I will do a breech birth, but you must have an epidural, must this, this and this. And under those circumstances, when the woman is on her back with an epidural, they have to do these maneuvers because the mechanism of a breech birth really only works when a woman's on hands and knees. So when she's not on her hands and knees, you almost have to mimic that positioning of the baby as a clinician because she's reversed yeah.
Rixa:
[39:18] Yeah she's fighting gravity as the baby's coming almost up towards the ceiling instead of kind of falling down with gravity
Mel:
[39:24] Yeah and so do we have any research which compares physiological breech birth where the woman is able to move to when a woman is supine on her back with an epidural.
Rixa:
[39:39] Yes. So in the Leuven 2017 study, which is a large breech magnet center in Germany, where they started doing normal supine breech births, and then over this time span, transitioned to mainly physiologic breech on hands and knees or standing. So they had a cohort of the supine that they could compare against the cohort of their upright breech births from the same clinic, right?
Rixa:
[40:01] And they found that about 90, 95% of the supine breech burrs involved some kind of manipulation, whereas, you know, the vast majority of their upright ones were totally hands-off. And so these women had access to very good walking epidurals. So actually a good number of even the upright ones had epidurals, but I've seen videos. These women are standing, they're squatting, they're kneeling. They have enough sensation and mobility to actually move and feel. So I think it was a good number. I want to say off the top of my head, maybe even upwards of two thirds. So not everybody, but there was a good number who had epidurals, but there weren't like the dense ones that we have in the US, at least the ones I've seen when I was attending births. I mean, these women couldn't feel a thing. They couldn't even roll over under their own power. So it's a very different kind of thing that they are able to offer. So yeah, and there's another study by Bogner that had a matched cohort group of, you know, they matched the same number of upright versus supine from their same clinic and found kind of the same things. So we do know that it does make a difference, you know, in terms of how well it works and how smoothly the process goes. And an epidural, there's kind of mixed evidence on epidurals. Again, if you have a really good walking epidural, that's a lot safer. But the dense epidural, you can't feel a thing, you can't move, you're on your back in the operating theater. With your legs up in stirrups, that kind of epidural, that's bad news because it makes it a lot more difficult.
Rixa:
[41:26] And what frustrates me, again, getting my feisty Rick's hat on, is that where breach is reluctantly offered in some hospitals, it's like they're punishing the women and making it as miserable as possible. You must be in the operating room. You must have an epidural. I'm going to give you an episiotomy. You must have an IV. You must, you know, it's like all these horrible things that we're going to punish you with that you have to agree to. Of course, you're not going to want to do that they won't let you do anything else and so it's like you bad girl you know you have to do all these things that we say or you just choose the cesarean section and they'll be very nice to you that's a definite bias you know it's not respecting her at all yes
Mel:
[42:11] I have to agree with you and i guess i guess that's my question too do women have options when they have a term breech baby.
Rixa:
[42:21] Most don't. Let's just be real about it. In theory, legally, ethically, nearly every country has very, very strong laws that you cannot force any competent adult to have surgery. Okay, that's the law. And that's the theory.
Rixa:
[42:39] In reality, on the ground with breach, nearly every cesarean section that happens is an unconsented surgery, in the sense that they didn't give her full informed consent. They didn't say, they didn't support her right to refuse the surgery, which means a vaginal breech birth. If you say no to surgery, a vaginal breech birth is going to happen. It's not an elective procedure. It's physiology. It's inevitable. They didn't provide her. They didn't say you have the right to refuse surgery. They didn't say you have the right to choose a vaginal breech birth. They didn't present her the risks and benefits and alternatives of all the choices. So I would say that almost every cesarean section, even if they signed the darn consent papers, that was actually not a consensual surgery because there's actually really good laws, at least in the US, that if you don't provide the full range of risks and benefits and alternatives to all the possibilities, and if you don't support the right to refuse, that's considered non-consensual, even if you sign the papers. So I would say most women are having unconsented and therefore illegal and unethical surgeries. Because if you ask the average woman who had a cesarean for breach. Oh, did you have the full choice of vaginal breach birth presented to you as a reasonable option that was fully supported enthusiastically?
Rixa:
[43:51] Nobody's going to say that except maybe in like, you know, Andrew Bissett's in Sydney, who has the breach whisperer. And I think you have like, you know, we have like one or two hospitals in the entire United States that have a vaginal breach service. That do physiologic breach, and that basically offer that to women. I don't know, 300 million people, hospitals that I know are trying to change. Like I know Sarah Morris in Perth is working on starting a midwife-led breach service. You probably know Sarah. We have quite a few hospitals that are starting breach programs or trying to get them off the ground. But isn't it ridiculous that every major city in our country doesn't have at least one hospital that offers this 24-7?
Mel:
[44:29] Privacy and this is i mean we're fortunate there's westmead hospital not too far from me which has a breech clinic but i know that that i i my understanding and i could be completely wrong i'll get some angry emails is that they are encouraging women to have epidurals but they are offering a service where breech vaginal birth is welcome and this is the choice that women are being presented with is we can do a cesarean section it'll be fine it's that you know time that we can all choose it'll be calm you know it'll be lovely or you can have a vaginal breech birth but would you want to if you knew that your clinician had no skills in vaginal breech birth or theoretical skills in vaginal breech birth and it was the first time that they were doing it, if you are informed yes you can have a vaginal breech birth however this will be the very first time that will have ever done one would you like a vaginal breech birth or a cesarean birth.
Rixa:
[45:41] And it's not a fair choice, is it? It's not like two alternatives that are equal and you just weigh and you make a choice. It's like a really beeping, bleeping, I'm going to put some expletives here option that looks terrible or the nice cesarean section, you know, which nobody presents the risks of. typically it's very much like, oh, this is your safe option and this is your dangerous option. And I'm going to be terrified and everybody's going to be panicked and nobody's excited and happy. Everybody's stressed. It's like that's not – that's really not a good choice.
Mel:
[46:14] Well, and let's talk then about the fact that women are told about the risk to their baby of the vaginal breech birth versus cesarean section birth. But that's not the only risk that's involved here because what they won't do is list through the risks of the current cesarean section or the risks that are now being transferred from this birth to the next birth when they may attempt, for example, a VBAC or a second cesarean section or a third, fourth cesarean section. And the more cesareans you have, the higher your risk of various things build up. So if we're thinking about a more holistic look at the risks of caesarean section versus vaginal breach birth, Can you speak to the risks of that current caesarean and also of the next births and how that balances out the risk for the individual woman?
Rixa:
[47:14] You know, back to the one in 500 for a planned vaginal breech birth versus one in 2000 for the C-section, one in 1000 for the normal head down birth, right? That's kind of some risk estimates in the short term. So you have to remember that that's balanced against all the risks of caesarean section short term, which is, you know, higher rate of death, higher rate of near death, higher rate of all sorts of morbidities, wound infection, all sorts of things that can happen during the healing process after a major surgery. And then you have the long-term risks of having a uterine scar. And so those are really interesting because they're not just maternal risk, they're also risk on all the future children. So the maternal risk end of things of having a uterine scar for long-term, like next pregnancies, reproductive future, are, you know, higher risk of having a uterine rupture, higher risk of having a placenta that's adhering in an improper way. So that's called placenta accreta, where it starts to grow into the uterine wall. And that's a really, really nasty complication. And that risk goes up with each cesarean section.
Rixa:
[48:15] You have a higher risk of almost dying after your cesarean section, but because you've had that scar with your next birth, regardless of mode of birth, you have a higher risk of almost dying as well. That risk of near death carries through your future pregnancies because of that first cesarean section, because you've opened up and done all the surgery. So you have a higher risk of what's called severe acute maternal morbidity that kind of sticks with you. But then your future children have a higher risk of dying as well because of having a cesarean section the first time. So, you know, you can save a certain number of babies the first time around by doing a lot of cesarean sections. But what happens is that the next time around, you actually lose...
Rixa:
[48:57] More babies, not quite as much as you saved, but it's starting to get close. Like, you know, so from the Netherlands, for example, there was a study that looked at about 8,500 cesarean sections right after the term breach trial, when they were doing a huge number of elective cesarean sections. And they said, they estimated looking at their before and after numbers of the mortality rate, like for 8,500 elective C-sections, it saved about 19 additional babies' lives, right? But the cost to that was four direct maternal deaths that were from the elective C-sections that were deemed completely avoidable, 140 additional cases of life-threatening maternal complications, and nine additional deaths in the next pregnancy above what the baseline rate should have been. So you save 19, but then you lose four mothers, you lose nine babies the next time, and you have 140 mothers who almost die. So it's not risk versus safety. It's you can have one risk
Rixa:
[50:03] Now, and have it be safer later, or you can get rid of a little bit of risk now for this first baby, but then have it be more dangerous for you and your babies later. There's no avoiding the risk. It's just, do you want it now? Or do you want it later in downstream?
Rixa:
[50:17] And the problem is too, is we're talking about statistical probabilities, but risk happens to you. It's either zero or 100. Your baby lives or it dies. You have an injury or you don't. So when it happens, you might have said I have a one in 1000 chance of it of something bad going wrong that sounds great to me and you're one of the one in the 1000 or or you're not and you can't that's the problem is we can't predict either way you know you can't predict the maternal death you can't predict the neonatal death you can't predict the rupture down the road and we I think we think that we operate as rational computers that just calculate risk and spit out what's the most probability and go up for that, but we honestly are not. We're going off culture and emotion. And we probably don't even understand most of the statistical probability. You know, we do things on our everyday life that is so incredibly dangerous. If you get in a car and put your child in a car and you drive, you're putting your child at risk, probably far more risk than your vaginal breech birth. But we do that all the time. So we're also hypocritical because we inflate certain risks And we run away from them in response. But then every day we do things that are risky and we don't really think about it and we don't shame each other for doing it. You know, what if we shamed every mother who got into a car with her children and told her what a bad mom she was and blamed her if she got in a car accident? That's what we're doing to women with breech babies.
Mel:
[51:46] It's up to you to navigate your risk profile and what's safer and what's not. Do you want to accept the short-term risks of breech birth or would you like to accept the long-term risks of having had a previous cesarean section? You know, we as clinicians can't even calculate risk. And, you know, so it's this topic of breach is so fraught and women ask me all the time, hey, my baby's breach. Do you think I should try and turn it? And the physiological home birth midwife in me says, well, if your baby's breach for its own reasons, then maybe it's better to leave it. However, maybe there's some things in your body that are causing it to be breached that you could correct, maybe like an osteopathic adjustment, or have you got some tight muscles that are impacting on the baby's capacity to turn? You know, do we do some spinning babies? Do we do some acupuncture, some moxibustion? So I'm torn between respecting and honoring, you know, the decisions that the baby has made potentially to be breach and and honoring that maybe that's the way it needs to come out.
Mel:
[53:06] And the actual fact that if a woman doesn't do everything to turn her breech baby, she may very well here in Australia be presented with cesarean section as potentially the safest or only option to have her breech baby. So I just really feel for women who are carrying breech babies and all the decisions that they have to make to turn it or not to turn it, to find a clinician or to just submit to a cesarean section.
Rixa:
[53:36] Yeah absolutely and you know i i haven't had a breech baby a breech birth myself but my second was breech for several weeks during pregnancy just via palpation and i was so stressed you know and this was this was before i was specializing in breech but i still had a good amount of knowledge and i was following a little bit of the research even at that point because i was just found it very interesting and it was so stressful for me um Not knowing, you know, maybe I had an option 10 hours away, but I didn't think I'd make it 10 hours because my first labor was 10 hours start to finish. You know, I had a midwife who was very supportive, but she had not attended a lot of breaches, although she'd done a lot of training. You know, just who would take care of me? Where am I going to go? I don't have any really good options that I feel comfortable in. And there's no way I'm going to submit myself to a cesarean section just because. And just having that few weeks of him being breached, and I was doing these things to try to make him turn. And I kind of like, I just wish I could tell myself, just stop, just stop worrying about it and stop trying to fix anything. It's not a problem, right? It just, you know, that, even that small peek into that was so stressful and so eyeopening.
Rixa:
[54:49] He just, you know, flipped on his own. I mean, you know, it was, it was, I knew in my mind, it was too early to fret about it, but my mind was not paying attention to, you know, my emotions and the fact that I was all of a sudden trying to scramble to figure out who would care for me and what am I going to do? And, you know, we have so many midwives who want to support it, but we also need to have some, I think, system-wide things pushing change, you know, besides the midwives who want to do it and the women who want it, but how do you get like more people motivated? That's, I don't know the good answer to that, but I also, I think that we need to put little teeth into it. So one idea I've been trying to float around and if I can gather enough lovely attorneys is to have a system where women who have a breech baby...
Rixa:
[55:40] And go to their provider or their hospital and they're told you don't have an option or, you know, we can't support this or we don't blah, blah, blah. You know, most women say it's just not an option where you can't do it. It's not allowed or we won't support it. You have to have a C-section. To have a network of attorneys who can write like a letter. I don't know what it would be called. It's not a cease and desist, but it's kind of the opposite. It's like, stop resisting letter. Like I'm putting you on notice that my client has been informed that you're going to violate her legal right to refuse surgery and her legal right to inform consent that you're refusing to support a vaginal breech birth. And I'm just putting you on notice that this is not legal. It's not ethical. And we expect that you get your providers trained and support her desire for a physiologic breech birth. You know, if anything happens, I will happily, you know, represent her. It's just like a little bit of a threat behind it, like, but not coming from the provider, but coming from like an attorney. Right. So it's outside of the health care people, you know, so that the midwives don't get in trouble. I kind of think it'd be really lovely to have like all these letters coming to all the hospitals saying, my right is to refuse surgery. You're not supporting that. You have no one trained. I'm putting you on notice that you better get your button to gear, get some training because, you know, kind of a little bit of a movement. I don't know. I hate to I hate to resort to legal means, but I think we kind of need it.
Mel:
[56:59] Well, the other option is that we petition the universities or colleges to actually make it mandatory to have skills in breech birth for midwives and obstetricians. And actually, if you're unable to attend a breech birth, then you haven't got the appropriate competencies to be a midwife or obstetrician. Like you're incompetent.
Rixa:
[57:25] Yeah. They have to have some kind of a skill certification. certain minimum numbers of education and even if they can't attend a certain number of actual births like certain number of simulated births and a certain kind of minimum training standard yeah that's not unreasonable
Mel:
[57:39] Well no i mean i mean if i go to uni you know as a midwife we had to tick off that we had done yes i did 30 vaginal exams yes i did 30 normal vaginal births and you have to get tinked off as competent before they'll allow you to be registered as a midwife i mean And I'm sure there's a similar process for obstetricians who are learning vacuum extractions and forceps and cesarean sections and all the skills they need to manage more complexities at birth. They would have to demonstrate some kind of competence, whereas breeches have fallen off the competency list. And so actually, we've become incompetent as a profession.
Rixa:
[58:23] Yeah.
Mel:
[58:23] So maybe instead of like going from the legal standpoint, the hospital has already received this huge batch of incompetent staff. We go back to the very, very beginning where they teach them how to be midwives and obstetricians and teach them how to do breech beds.
Rixa:
[58:41] I am 100% behind that as well. I think it would be lovely, wouldn't it? That everyone comes out with a certain minimum level of training and education. Because honestly, so much of the resistance is fear because of the unknown.
Rixa:
[58:55] They've never really seen it anyway. They've just heard vague horror stories. They probably haven't read the medical studies. They just have this vague idea that it's really scary and really dangerous and really difficult. And that's kind of the extent of many people's education. And maybe they've seen some scary breach extractions and that's it. So yeah, I think most people when they're exposed to it and they understand, oh, how does this work? Okay, this makes sense. I understand the mechanics of it. I understand how I can resolve a problem and I can recognize what to do and when and why. They lose the fear. You can still have a healthy respect and a little bit of fear. I think that's, you know, reasonable, but you can, you can mostly just approach it with caution and respect and a little bit of, you know, like you approach it like an ocean with big waves, right? It can be fun. It can be a little scary, but you make sure you have some reasonable boundaries. You know how to swim and you know how to watch for riptides and you, you have a great time, right? You play in the waves and you do your best and you could sit in your little bubble on the beach and never go in the water. So I think vaginal breech birth can actually be fun. I mean, I'm not going to fairy coat it and be, it's all, you know, sparkly unicorns all the time. It can be really difficult sometimes. Some of these births can be quite challenging, but most of the time it isn't. And so how do you balance that respect with the joy of attending births? And I think it'd be amazing to have people who are educated enough that they lose the fear and they can just become very excited about it.
Mel:
[1:00:20] I mean, kind of remember, obstetricians' whole job is to deal with situations that are complex and scary.
Mel:
[1:00:31] It's part of their skill set. You know, us as midwives, we have the fun job of nurturing women all through their labor and then watching the baby come out. And then if all of a sudden things fall out of our scope and we think, well, this is not my job anymore because that is out of my comfort level and scope, then we push the button and in comes this beautifully skilled obstetrician whose job it is to take over and take responsibility for clinical care when it's no longer in the midwifery scope so in fact their whole life their whole careers they are coming into these uncertain situations that are complex so it's bizarre that breach has fallen out of that and they are actually should be experts in managing their fear in perfecting their skills for complex birth so that they can fulfill their actual role as obstetricians that's not a rebellious idea that's just the truth it's reality yeah right I think what we've discovered is that current practice doesn't match with current research but we spoke about the term breach trial.
Mel:
[1:01:44] Which was the final nail in the coffin for breach because it was a randomized control trial. But there's other research that is less dire than the term breach trial. Can you briefly speak to what else exists that potentially women or clinicians could access to help them get a more full understanding of breach birth statistics?
Rixa:
[1:02:05] Yeah, there's a huge body out there. So some of our lectures in our training programs cover that. So I have one that's about evidence since the term breach trial. So looking at the last 20 years and the evidence falls into a couple of main categories. So you have single center hospitals where you just like look at what happened in one hospital over a 10 years or 15 year period. Then you can have multi-center studies. You pull your data between lots of hospitals. Then you can have national registry studies where you look at everything that's happening in the entire country over a long time span, like 10 years or 15 years. And then, you know, so there's, you know, the more numbers you have, the more useful it can be sometimes, although you lose some of the detailed information.
Rixa:
[1:02:47] So and then we have a whole emerging body of evidence about physiologic or upright breech birth specifically. I have actually a whole lecture dedicated to kind of a research update of what's been published about physiologic breech birth and what do we know and what are people doing? Because I think that most women who nowadays want a vaginal breech birth are the kind who also want an unmedicated physiologic breech birth, you know, that's the clientele that you're getting who are really motivated. So that often meshes quite well with their desires anyway. Not all, of course, but I think most of them are the type who would maybe want a midwife or a home birth anyway. And so they're, they're really motivated to seek that out. So it's really hard to summarize it all in a very short time, but it's out there. You know, we have it in some of our training courses, we have some individual lectures, like on our website, for example.
Rixa:
[1:03:38] So, you know, it's, it's a lot to wade through. So it's nice to have someone kind of guide you through what's out there and how to understand it. Speaking as, you know, in a kind of global sense, if you're looking at like what's been coming out in the last 20 years, the term breach trial is definitely an outlier in terms of its conclusions. And the rates of mortality and morbidity are not reflected in almost every other study, which are finding much lower rates of injury and death. You know, there's still usually most of them find a little bit of a difference between vaginal breach and plant cesarean section. still not for surprising. But usually those rates are much, much smaller and much closer to zero than the term breach trial. And that's a pattern that we're seeing emerging. I just don't think it's really much of an applicable situation to most places on the ground. And the 20 plus years of research coming since, which are not randomized controlled trials, but they're actually researching what's happening all around the world in very large numbers. It's just not reflective of that level of risk. And my earlier point stands to the more skilled, the more experienced you are as an individual practitioner, but also as a culture or a country, the better your outcomes can be, which I think is such an important reason to get everybody trained. I mean, besides the fact that it's their job, right, as an obstetrician or a midwife to be able to handle these, you know,
Rixa:
[1:04:56] Shouldn't we try to make birth safer? I mean, if we don't have the skills, you know, a quarter to a third of breaches are still undiagnosed at the beginning of labor. So we still have a good number of surprise breaches, and we can't avoid them all.
Rixa:
[1:05:10] So I just think it makes so much sense to have the skills and the training. It's getting late. You know, I can understand if some people just don't want to go there for doing planned vaginal breech births. But shouldn't you get the skills for everybody? And then let people specialize. If you don't want to do it yourself, don't be the obstacle in the way of other women and other providers doing it. Be a champion and a supporter. Refer. You know, if you know of a colleague who's trying to support vaginal breech birth, give him or her your clients. make sure that that colleague doesn't get into trouble because there's a lot of peer-on-peer bullying among obstetricians. I've done some research on this in a thing that I'm working on publishing where the ones in hospital who are supporting vaginal breech birth are harassed and bullied like crazy from their colleagues and their administrators and their department chairs.
Rixa:
[1:06:04] So be a champion and a supporter, even if you yourself don't want to be the one that's actively supporting it, do everything you can to facilitate that for those who'd want to. And I think we could just have such a better workplace environment if we had that spirit of collaboration and curiosity and collegiality and it doesn't have to be so terrifying and scary and you know the people who want to do it can self-select everybody should have a baseline amount of training and then those who really want to specialize can take it on and just run with it but we just shouldn't stand in the way and we should actively support and uplift those who want to
Mel:
[1:06:41] Yeah. And at the very least, each hospital needs to have some referral pathway or the skill set or a experienced clinician, at least if there's an option that a few people will do it and then supporting it. Riksa, you work very, very hard on Breach Without Borders. And in fact, Breach Without Borders is coming to Australia through April and May.
Rixa:
[1:07:04] April, I think it's starting as early as March, maybe even. Yeah. I have to check our schedule. We're coming for a few months. Yeah. It's so, I'm so excited.
Mel:
[1:07:12] There's a lot of training. I'm going to the one here. There are so many happening over the months, March, April, May. So if you're listening to this and you're in Australia, and I know that like 80% of our listenership is Australian, you have the opportunity to become trained in breach. And in fact, we have the opportunity as midwives to take this back into our midwifery skillset. So I'd encourage you to go along, but also Breach Without Borders has this incredible online courses. And I believe the online courses are a prerequisite to the live workshop sessions. Is that correct?
Rixa:
[1:07:51] Yeah, they're bundled. So when you enroll for the hands-on training, the online course is included, or if you're already signed up for it, you get a discount and you have to finish the online course before you show up for your hands-on training day. And it's a big course and it takes some time, but we really feel that you are much better trained provider coming out of it if you've done all the prep beforehand and done all the lectures and learned everything and then you come for a really intense day of hands-on simulation training beautiful
Mel:
[1:08:16] So yeah i guess my call to action for this episode is to at the very very very least even if you can't do the live hands-on workshop is to get the online resources which are by the way way too cheap i think you need to increase the price on those but there's in terms of how much you get it's very very cheap and then if you can get yourself along to a live training in Australia you might not be able to for another few years so you know it might.
Rixa:
[1:08:48] Be a while can I show you something else I know you you listeners can't see it but it's my six pound baby available for purchase in Australia I'm showing her the second edition of our textbook a guide to physiological breach birth. So it is so gorgeous.
Mel:
[1:09:05] Is that on the website?
Rixa:
[1:09:06] It's on the website store. You can buy it. It ships to Australia from New Zealand and it's 550 pages, full color, thousands of photographs. It's a kind of a comprehensive breach textbook training manual. 39 parent stories, 28 guest chapters, and 20 main chapters. So it's my little plug to buy our book and learn more about Breach.
Mel:
[1:09:27] Yes. All of the links to all of this that we're talking about will be in the show notes below. So you can click straight on through to Breach Without Borders, reserve your spot in a workshop, buy the book or the online course. And if you're part of the mailing list, you will get access to the free resources that we use to create every single podcast episode so get on the mailing list at melanethemidwife.com and rixa i'm going to thank you for your time is there any final words that you had that you feel like we did not get out today.
Rixa:
[1:10:03] I think we covered some great points. You know, I have some crazy stories that I might have to tell in another podcast. Like next, next time we chat, this is a little teaser. Maybe we'll chat again. Ask me to tell you the story of how I was born. That's a teaser for the, maybe another episode.
Mel:
[1:10:20] I can talk about some crazy stuff.
Rixa:
[1:10:23] Little, little, little hint. I was born with my mother hanging upside down from her ankles by the ceiling.
Mel:
[1:10:29] Stop it.
Rixa:
[1:10:30] Yes.
Mel:
[1:10:32] Okay well i was.
Rixa:
[1:10:33] Literally she was literally upside down
Mel:
[1:10:35] We will definitely have to have you back to hear that story full stop because i'm not going to do it now because i do want people there's no time there's no time and then they can come back and listen to the next episode with rixa incredible okay well farewell that was amazing to get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
©2026 Melanie The Midwife
