Irene de Graaf: Risk, Rules, and Reality

First Amsterdam Breech Conference, Day 1

Irene de Graaf

Risk, Rules, and Reality

Irene de Graaf, MD PhD, is a neonatologist who focuses on shared decision-making and who works with women who go outside of the expected medical protocols. In her presentation, shared her thoughts on breech birth and the reality of her daily practice.

Together with a midwife, doula, and obstetrician, Irene runs an outpatient clinic offering tailor-made care in obstetrics. It is called Poli Ondersteuning Maatwerk zwangerschap & geboorte (POM). This includes women who wish for medical interventions outside established guidelines as well as women who want a natural birth outside those guidelines. She sees women who want no fetal monitoring during labor, who want to birth in a vertical position, and who want to be supported by their own midwife at home. She also sees women planning cesarean sections who want to to wait until labor begins before having the surgery.

Irene referenced a 2015 meta-analysis about the risks of planned vaginal versus cesarean birth for term breech babies. She also referred to both the Dutch and RCOG guidelines for breech babies. In her clinic, they do not force any guidelines on the women they care for. Her experiences working with women outside the borders of normal medical practice sparked several questions:

1. Why do women want care outside the normal guidelines?

• Fear of cascade of interventions
• Fear of being treated as number, as a victim of protocols
• Fear of losing autonomy
• Strong belief in their own strength and intuition

2. Why do doctors not want to make exceptions to breech guidelines?

• Fear of being responsible if guidelines aren’t followed
• Fear of breech birth
• Strong belief in numbers
• Desire to rule out every (small) risk
• More confident in doing things they can control

3. “If we want, we can.” We have to be response-able—able to respond to different situations.

4. Why can’t we solve this issue? Irene identified several practical solutions:

• Centralizing breech services would focus breeches in one location and give providers more experience
• Train practitioners
• Open your clinics so that others can watch & learn breech skills
• Listen to the expectations of pregnant women
• Support women's decision making

For answers to more of these questions, she suggested that we "ask the midwife!"--specifically, Dutch midwife Rebekka Visser, who was the next speaker.