This is a bit outside the norm, but as I get closer to the 1-year anniversary of my kid’s birth (also known as the first birthday!) I figure maybe it’s a good time to write down the slightly abridged version of her birth story.

Sure, every mom has a birth story for every kid. And who really wants to hear it? Well, other moms or moms-to-be; maybe other folks with an academic or personal interest; and in this case, people dealing with breech birth. My kid’s story is a bit odd and is a little window onto medicine in America today. But if you don’t want to read birth stories, here is your moment to exit! Leave now! It’s not graphic, really. I did say slightly abridged, after all!

Let’s start the story at about 34 or 36 weeks. The average first pregnancy Is about 41 weeks so this is getting within sight of the end. I was going to my local birth center and having regular prenatal visits with the lovely midwives, not really getting into the aromatherapy idea per se and not getting invested in waterbirth, failing to draw up a comprehensive birth plan, but figuring it would be enjoyably granola since I was a low-risk healthy mom. There was a little shadow of partial placenta previa but I’d looked up the stats and 80% of such cases resolved by 36 weeks. Pretty good! Why worry?

At one of these earlier visits the midwife checked all the baby vitals and made approving noises. Perfectly on target for growth, great heart rate. A little puzzling this lump here as opposed to there – could be breech, but maybe not, and you know babies turn. Maybe do some inversions, some pelvic tilts, ok honey?

Next visit: perfectly on target for growth, good blood pressure, good heart rate. Ultrasound to check that partial placenta previa: looking good! You’re back to a good placental placement, so you can continue with the birth center! But oops… maybe this kid is still breech. The due date is getting closer, so let’s just check again. Yep! Breech baby. You’re going to have to keep up those inversions. Maybe have a conversation with your baby. I know you’re a science-y type, but try this homeopathic remedy. (I do – at $6 a tube, it’s expensive for sugar pills but cheap compared to a C-section.) And it’s getting late enough in your pregnancy that you’re going to have to look at some options. If your baby is breech, it’s illegal for us to keep you as a patient. Why don’t you schedule an external cephalic version and see if you can get this baby turned? We’ll make some calls for you.

This is how I ended up hoisting myself onto an ironing board to lie upside-down for 20 minutes a session, three times a day, until I decided it was stupid and made my back hurt. This is how I tried playing with flashlights and playing Norah Jones through headphones stuck into my waistband (it worked for one lady!). This is how my husband & I ended up in rural Wisconsin trying to convince our baby to do a somersault.

Forty minutes drive. City center to suburban strip malls to apple farms to corn fields. The doc out there had good hands. Very calm, very experienced, easy-going. After I got all the monitors placed and a comprehensive explanation of the risks, he firmly pushed & massaged my enormous belly. No budging. He gave it a rest, we chatted, and he tried again. Pushed quite firmly on that baby, but baby did not budge. The doc stopped, looked at me, said, There’s no point in being too aggressive. This baby is wedged into your pelvis and does not want to move. Further pushing will bring more risk and I don’t think it will work anyway. We need to keep you here an hour to make sure everything’s ok. In the meantime, you should start making plans for having a breech baby.

Gone, visions of D’Amico and Sons pasta after a night of laboring at the birth center on Grand Avenue in Saint Paul. Gone, sitting on the porch on a birthing ball and watching evening traffic go by. Gone, the low-intervention model of birth center care.

Hello, sense that the medical system was a racket, that we’d be railroaded into a procedure that would not be considered medically indicated were we in Europe. Hello, the feeling that every hospital in the Twin Cities had spent more time picking out the tile for the tub room in the birthing suite than finding OB/GYNs who could care non-surgically for this normal birth variant. Hello C-section! Right?

My husband & I had started reading tons of stuff about external cephalic versions, breech pregnancies and births, and the general state of American obstetrics by this point. He’d called a family member who was just finishing her OB training to get the low-down on current training. She said current training was zero, and her profs felt that any doc trying a breech delivery was involved in dereliction of duty. (Full disclosure: he’s also a doc, albeit for grumpy men rather than preggo women.) We’d found the 2001 study that basically decimated the practice of vaginal breech delivery in the US; the study was halted due to adverse events in breech delivery. We’d found the criticisms of the study, and the later stats that showed no difference in infant mortality or morbidity outcomes between vaginal breech delivery as compared to C-section by age 2. We’d found the stats on European breech birth. We were aware we were looking at a guaranteed C-section if we stayed in St. Paul/Minneapolis, aware that in fact some OBs would refuse care or go as far as mandating care without consent in these cases, and certainly aware that we could no longer have the relatively low-intervention birth center birth we’d planned on.

One or two friends or acquaintances half-jokingly suggested a home birth, but crunchy and granola as I am, I was dead set against that. Unnecessary medical intervention is unnecessary. There’s no reason to be scalpel-happy just because. But damn, medical intervention has dropped mortality rates!! I love not dying! I do like the option of surgery when it’s useful!

This is where luck was on our side. The doc who’d done the failed external cephalic version had actually done a lot of breech deliveries and was at this hospital in rural Wisconsin now because they’d offered him the position of head OB/GYN with the freedom to oversee his department as he saw fit, in accord with ACOG guidelines. (He’d left another position in adjacent rural Wisconsin concurrent with that hospital’s decision to ban all vaginal breech deliveries. I don’t know that the breech delivery ban was the impetus for leaving, but…)  We talked with Wisconsin Doc and he said that if we wanted to drive out there for the birth, he’d come in no matter when it happened. For “normal” births he had a weekend replacement, but for a breech birth he’d do it himself regardless of the date or hour.

After five hours of conversation with the insurance company we were able to get a referral to Wisconsin doc for the remaining two prenatal visits and the delivery. We got a backup referral to the University of Minnesota medical center, as it was closer to home. I figured if baby came during rush hour there was no way we could make the commute out to Wisconsin, but if baby came at a low traffic time we could drive on over to the boonies and attempt a vaginal birth. The C-section room would be right down the hall in case of need, and an oxygen tank would be in the room. The kid’s umbilical cord was in a good place, not in danger of slipping between baby and pelvis and not around the neck, and the kid was frank breech, so we were good candidates for attempting a vaginal breech delivery. Our birth-center midwives were visibly happy with this outcome though sad to see us go – they’d worked with Wisconsin Doc in the past. They had to hand over care and say good-bye to us, saying they could do one post-natal follow-up visit.

It was a whirlwind of change at this late date in the pregnancy. Instead of picking out room decorations we were finding a new doctor and reading medical studies. We decided we’d want a doula and started interviewing at the last minute, looking for someone who could support either a breech birth or a C-section. My husband got pretty in-depth in studying up on breech deliveries – I think he was afraid he’d have to deliver the kid himself on the side of the highway or something. Wisconsin Doc had gone over all the studies with us too: Breech delivery was associated with low initial APGAR scores, higher initial infant morbidity and mortality, and no change in infant morbidity or mortality by age two (?!) compared to C-section for breech babies. Vaginal delivery is generally safer for women in the context of modern medical care, and C-sections basically shift the morbidity burden to moms. (Yeah, we don’t talk about that much.) We found a doula and made a plan. I gave my final exams and was prompted by a friend to take some pregnancy photos on May 13. Finished grading finals, started grading senior projects in mathematics.

Early on Mother’s Day 2017 I woke up to the sound of a musical note being plucked inside me and a gush of water. Two in the morning. I entered interim grades for my senior projects and hung out alone, texting the doula and letting my husband sleep as I wanted him to be awake for the drive. Four am I told him we had to go to Wisconsin. He tries to run a little diagnostic questionnaire on me (he’s a professional!) and I tell him to shut up and get in the car, although I believe I’m more polite than that. We drive for 40 minutes and the doula and a hospital attendant meet us at the door. No traffic at 4 on a Sunday morning. Six am: Wisconsin doc shows up with coffee and a newspaper. He sits in the rocking chair in the corner & catches up on the news. 7:20-7:40 am or so: I believe I am going to die, and I say so. Wisconsin Doc and the doula laugh. That sounds like a woman who’s going to have a baby! 8 am: I’ve got a baby girl. As expected, she needs a puff of oxygen – not even a mask, just a puff at her face. She starts to cry. I don’t remember all that much at this point. 9 am: We’re in another room all together and I’m having a fine Wisconsin omelette with an enormous amount of cheddar cheese.

Vaginal breech delivery is a tricky thing. Indications are that it’s a relatively safe thing to attempt if you follow current ACOG guidelines for progress, with the option of a quick C-section in case of deviations from the standard course. I also believe (supported by some evidence but no randomized control trial) that an average OB/GYN with experience with breech deliveries has much better outcomes than an average OB/GYN without experience, not least because an OB/GYN unexperienced in breech delivery is often trained with a bias that breech deliveries are dangerous. This mindset is self-fulfilling, leading to interventions with bad outcomes. (Sadly, the linked article is full of bad ideas. Episiotomies? Maneuvers to extract the kid? All contraindicated by actual evidence!) Trying to carry out a breech delivery while a laboring woman is lying on her back is hard right off the bat: you need to carefully maneuver the baby to get the head out and it just seems non-optimal by all accounts. The best position for delivery is hands-and-knees, but not all OB/GYNs are experienced with this or trained in it. Then in a breech delivery you want to refrain from touching the kid until the last minute, in contradiction to the Medscape article above. Pulling on the child can result in spinal cord trauma and problems with the head getting stuck in the birth canal. Obviously you don’t want the head getting stuck – the kid can’t breathe then – but hurrying things in an attempt to avoid that actually creates additional problems and doesn’t solve the first problem. Patience and experience are crucial. A doc who can let things be as long as they’re proceeding well is the only kind of doc you want for a vaginal breech delivery.

We were lucky to find a doc with experience, a doc who could tell us how things usually go and what to expect. That low initial APGAR didn’t make him panic because that’s normal and not indicative of poor outcomes with breech deliveries, and indeed the 10-minute APGAR was fine. Wisconsin Doc encouraged hands-and-knees positioning and the use of a birthing stool, and with his nurses created a calm and competent environment. (Can you believe I didn’t have a cervix check ever until I was way in labor? That’s how every pregnancy should be!) I’d decided that if I had to give birth in a St. Paul/Minneapolis hospital I’d just prepare myself for a C-section – I definitely did not want an inexperienced doctor attempting a breech delivery, and I did not want to spend a lot of time in labor arguing with hospital policies or trying to school some doc in statistics.

All’s well that ends well, kind of. I’m still sad that there is so little support for vaginal breech delivery in the US. 96% of breech births in the US are by C-section. What else are you going to do if docs are no longer trained in breech delivery, are penalized by hospital policies on breech delivery, and always win in malpractice court if they do a C-section but never win if they attempt a vaginal breech delivery? (Remember, on a legal level if mom dies it’s unfortunate, but if baby dies you’re in real trouble.) Our female first-born breech baby ended up having severe hip dysplasia, so severe that the first pediatrician who checked did not catch it. But the second pediatrician did catch it and by day 9 of her life she was fitted with a Pavlik harness, which she wore for 3 months straight to successfully treat the condition. She’s a cutie who is climbing stairs and trying to walk here at her first birthday. We can thank our lucky stars (or whatever else you want to ascribe it to) that I could avoid a C-section and have a cheap, friendly, healthy birth experience out in Baldwin, Wisconsin, with my little butt-first baby.