My letter to DeKalb Medical regarding their reaction to a breech twin birth

Last week, DeKalb Medical revoked See Baby Midwifery's privileges after Dr. Bootstaylor attended the birth of breech-breech twins. The parents of the twins--both born with excellent Apgar scores-- wrote a letter this week attesting to the quality of their care. They lived 4 hours away in Savannah and relocated for the last month of her pregnancy in order to have the chance of a vaginal birth.

Dr. Bootstaylor is meeting with DeKalb today to discuss the situation. I wrote the following letter in support of See Baby Midwifery and Dr. Bootstaylor. (Click on the image for a PDF version.)

Monday, May 15, 2017

Dear DeKalb Medical,

I am writing to express my extreme consternation about your revoking See Baby’s privileges. As I understand the situation, Dr. Bootstaylor supported a family who wanted a vaginal birth for their breech-breech twins. The twins were both born with excellent Apgar scores; the second twin sustained a long bone fracture that is healing without complication.

I am a maternity care researcher and academic, and one of my main research interests is vaginal breech birth. I am also a mother of four children, so restricting women’s choices in childbirth is a personal issue as well as a professional concern.

I am currently collaborating with a British midwife and breech expert, Shawn Walker, to help hospitals safely implement vaginal breech services. As the evidence mounts that vaginal breech birth can be a safe option, especially when supported by experienced providers (1), it is unethical to ban women and their providers from the option of a vaginal breech birth. Studies on breech-first twins are rare, but the best evidence indicates that cesarean section is no safer than vaginal birth (2). The most recent ACOG practice bulletin upholds vaginal breech birth with experienced providers (3).

I want to remind you that banning vaginal breech birth or vaginal twin births by removing experienced providers such as Dr. Bootstaylor forces women to have surgery without their consent and forces providers to coerce their patients into surgery. This directly violates the principle of informed consent, which includes the right to informed refusal (4). AGOG’s May 2016 practice bulletin strongly upholds pregnant women’s right to refuse medical treatment. It reads:

[A] decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected. The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for obstetrician–gynecologists to attempt to influence patients toward a clinical decision using coercion. (5)

Forcing women to have cesareans for cases such as breech, twins, or VBAC also violates U.S. legal rulings that uphold the right of competent adults to refuse surgery (6). In particular, the Georgia Medical Consent Law has a section on the “Right of persons who are at least 18 years of age to refuse to consent to treatment”:

Nothing contained in this chapter shall be construed to abridge any right of a person 18 years of age or over to refuse to consent to medical and surgical treatment as to his own person. (31-9-7) (7)

I have read Jessica and Kevin Hake’s statement about why they chose to have their twins with Dr. Bootstaylor. Nothing in that letter shows evidence of illegal, unethical, or unsafe practices. In fact. Dr. Bootstaylor’s commitment to patient advocacy by respecting Jessica’s right to informed consent and self-determination should be commended.

Short-term morbidity, such as a long bone fracture, can happen after cesarean sections, including cesareans for breech babies (8). Forcing all women to have cesareans for breech or twins because of a long bone fracture is as illogical as forcing all women to have cesareans to avoid shoulder dystocia, or requiring all women to have vaginal births to avoid placenta accreta.

Women who have cesarean surgeries face a higher risk of death (9). Their subsequent pregnancies have worse outcomes than those of women who had vaginal births (10).  Removing the option of a vaginal birth for women with breech, twins, or uterine scars births forces these women to undertake these risks, often with no added benefit.

The See Baby team is one of the few practices in the area—even in the state, as the Hake’s story can attest to—that offers women a full range of choices. I urge you to reinstate See Baby’s privileges. I also urge you to encourage all maternity care providers at your hospital to provide full informed consent and a full range of choices to their patients, including the right to refuse a cesarean in favor of a vaginal birth.

All women deserve to give birth in the manner of their choosing, free of coercion. The law requires it. Medical ethics demands it. And most importantly, women want it.

Sincerely,

Rixa Freeze, PhD

References

1.

• Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407–12.
• Albrechtsen S. Breech delivery in Norway—clinical and epidemiological aspects [dissertation]. Bergen: University of Bergen; 2000:1–68.
• Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11.
• Haheim LL, Albrechtsen S, Berge LN, Bordahl PE, Egeland T, Henriksen T, et al. Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team. Acta Obstet Gynecol Scand 2004;83:126–30.
• Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? Eur J Obstet Gynecol Reprod Biol 2003;111:122–8.
• Kumari AS, Grundsell H. Mode of delivery for breech presentation in grandmultiparous women. Int J Gynaecol Obstet 2004;85:234–9.
• Rietberg CC, Elferink-Stinkens PM, Brand R, Loon A, Hemel O, Visser GH. Term breech presentation in the Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. BJOG 2003;110:604–9.
• Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcomes in the Netherlands: an analysis of 35453 term breech infants. BJOG 2005;112,205–9.
• Uotila J, Tuimala R, Kirkinen P. Good perinatal outcome in selective vaginal breech delivery at term. Acta Obstet Gynecol Scand 2005;84:578–83.

2. Blickstein I, Goldman RD, Kupferminc M. Delivery of breech first twins: a multicenter retrospective study. Obstet Gynecol. 2000 Jan;95(1):37-42.

3. American College of Obstetricians and Gynecologists. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol 2016;127(2):e54–61.

4.

• Chavkin W, Diaz-Tello F. When Courts Fail: Physicians’ Legal and Ethical Duty to Uphold Informed Consent. Columbia Medical Review. 6 Mar 2017; 1(2): 6-9.
• Goldberg H. Informed Decision Making in Maternity Care. Journal of Perinatal Education. 2009; 18(1): 32-40.
• Hammami MM et al. Patients' Perceived Purpose of Clinical Informed Consent: Mill's Individual Autonomy Model is Preferred. BMC Med Ethics. 10 Jan 2014; 15: 2.
• Kotaska A. Informed Consent and Refusal in Obstetrics: A Practical Ethical Guide. Birth. 2017; 00: 1-5.
• Moulton B, King JS. Aligning Ethics With Medical Decision-Making: The Quest for Informed Patient Choice. J Law Med Ethics. Spring 2010; 38(1): 85-97.

5. American College of Obstetricians and Gynecologists. Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. Obs Gynecol 2016;127:e175–82

6. See, for example:

Union Pacific Railway Co. v. Botsford, 141 U.S. 250, 251 (1891)
Schloendorff v. Society of New York Hospital, 105 NE. 92, 93 (N.Y. 1914)
Cruzan V. Director, Missouri Dept. of Health, 497 U.S. 261, 270 (1990)
In re Brown, 478 So.2d 1033 (Miss. 1985)
Cruzan V. Harmon, 160 S.W.2d 408, 417 (Mo. 1988)
Matter of Guardianship of L.W., 482 N.W.2d 60, 65 (Wis. 1992)
In re Fiori, 673 A.2d 905, 910 (Pa. 1996)
Stouffer v. Reid, 993 A.2d 104, 109 (Maryl. 2010)

7. Code 1933, § 88-2907, enacted by Ga. L. 1971

8.

• Canpolat FE, Köse A, Yurdakök M. Bilateral humerus fracture in a neonate after cesarean delivery. Arch Gynecol Obstet. 2010 May;281(5):967-9.
• Capobianco G et al. Cesarean section and right femur fracture: a rare but possible complication for breech presentation. Case Rep Obstet Gynecol. 2013;2013:613709
• Cebesoy FB, Cebesoy O, Incebiyik A. Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery. Arch Gynecol Obstet. 2009 Jan;279(1):73-4.
• Farikou I, Bernadette NN, Daniel HE, Aurélien SM. Fracture of the Femur of A Newborn after Cesarean Section for Breech Presentation and Fibroid Uterus : A Case Report and Literature Review. J Orthop Case Rep. 2014 Jan-Mar;4(1):18-20.
• Kancherla R et al. Birth-related femoral fracture in newborns: risk factors and management. J Child Orthop. 2012 Jul;6(3):177-80.
• Matsubara S et al. Femur fracture during abdominal breech delivery. Arch Gynecol Obstet. 2008 Aug;278(2):195-7.
• Morris S et al. Birth-associated femoral fractures: incidence and outcome. J Pediatr Orthop. 2002 Jan-Feb;22(1):27-30.
• Rasenack R et al. [Fractures in neonates as a result of birth trauma caused by caesarean section]. [Article in German] Z Geburtshilfe Neonatol. 2010 Oct;214(5):210-3.

9.

• van Dillen, J., Zwart, J. J., Schutte, J., Bloemenkamp, K. W.M. and van Roosmalen, J. (2010), Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstetricia et Gynecologica Scandinavica, 89: 1460–1465.
• Schutte JM, Steegers EA, Santema JG, Schuitemaker NW, Van RJ. Maternal deaths after elective caesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand 2007;86:240–3.

10. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.