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IT'S 3AM in delivery suite nine of Newcastle's John Hunter Hospital, and obstetrician Andrew Bisits is intently watching the arrival of my first baby. Bisits is officially on three weeks' holiday from his post as John Hunter's obstetrics director, but only hours ago dashed back from watching the Waratahs draw 16-all against Western Force in Sydney.
Bisits and midwife Tracey Webb hand-signal and whisper. First the tiny bottom emerges, followed by a pair of ruddy dangling legs and two little arms. After a moment, our little boy's head emerges.
There is silence as baby Finn takes in his new surrounds, then a waa-waa as his first cry pierces the calm. His bottom-first arrival marks the end of an emotional journey to allow him to enter the world naturally. A fight for the right not to be "too posh to push" in a climate where the fear of birth complications is steering more and more women into the operating theatre.
Just two weeks before, tears had stung my cheeks after I was crudely stripped of the choice as to how my son would be delivered. At Sydney's Royal Hospital for Women, obstetrician Danny Challis had dug his hands into my abdomen and tried to manually turn our baby.
When Finn's bottom refused to budge from out of my hips, Challis announced that because the baby was not too big and was well-positioned, I would be perfect for a natural delivery.
"But we can't guarantee you [a vaginal delivery]," Challis said, eyes downcast.
Within half an hour we were shunted downstairs and booked in for an "elective" operation. No discussion, just here's your pre-op forms, thanks for coming.
My tears weren't for fear of an operation. They were for losing the right to make an informed choice, for having been completely disempowered in what was to be the most amazing event of my life.
Ironically, a NSW health department policy revealed yesterday will deny women the right to choose a caesarean delivery without medical reason, but will force doctors to be more open about the risks associated with a surgical birth.
Officially the Royal Hospital for Women says it doesn't prevent breech deliveries if a woman is in labour and there is an obstetrician on hand who is skilled in breech births.
In reality, because there is a very high chance that there won't be any such obstetrician available, the only option facing almost all mothers-to-be is to have an elective caesarean before labour even begins.
The situation has arisen as a result of the Term Breech Trial. Published in 2000, thecontroversial study was based on 2083 women in 26 countries who were randomly allocated to either breech delivery or caesarean section.
The trial found 5 per cent of babies born vaginally were injured or died at the delivery or in the early months after, compared with 1.6 per cent of those delivered by caesarean.
The results have reverberated globally and halted the natural delivery of breech babies in many countries. In NSW the number of vaginal breech deliveries almost halved, from 762 in 1999 to 383 in 2001. In 2005 there were 322 vaginal breech deliveries.
However, the study has its critics. They include Bisits (pictured above with midwife Angela Green), who says: "One of the major criticisms was that in [up to] 40 per cent of the deliveries, really the level of skill of the person at the delivery was questionable.
"I was actually shocked by the results of one in 20 babies being harmed as a result of vaginal breech deliveries. But when I looked at other places like Norway, places that did a lot of breech deliveries, infants with adverse outcomes were a lot less.
"We do have to appreciate that there are more risks to negotiate in a breech delivery, but they are negotiable. We can set up safeguards to make it a relatively safe and positive experience.
"I'd be reluctant to make the claim that you can reduce it to absolute parity with [a] caesarean section, but I think you can get pretty close."
Bisits says that a follow-up to the Term Breech Trial found that at two years of age, babies born vaginally had the same developmental outcomes as those arriving by caesarean.
Canberra Hospital obstetrician Professor David Ellwood says a major downside of the shift to caesareans is a loss of skills. This is a problem, because some breeches remain undiagnosed until the baby's bottom appears during labour.
"When I was training, which is 25 years ago, there was no way you would do [a] caesarean section for breech unless it was a footling breech, where you were very worried about cord prolapse," Ellwood says.
"We are now breeding the next generation of obstetricians who are going to be very poorly equipped for dealing with the relatively small number of breeches, quite often in situations where there is no alternative [because labour is too advanced]."
New Zealand midwife and author of Breech Birth Woman-Wise, Maggie Banks, says that as an avid watcher of the trial, the results came as no surprise. "The study's need to issue regular reminders as [to] how to deal with breech births was disturbing and indicative of a low level of expertise by some of the medical practitioners involved," she says.
Banks concedes that for women giving birth in similar circumstances to those in the study, where almost 65 per cent of women were either induced or given drugs to speed up the labour and 46 per cent were given an epidural, the findings are relevant.
However, Banks argues there is a better way to birth breech babies. She advocates an active, drug-free labour with the woman sitting or standing during the birth to help the baby descend. Banks says a woman's commitment to a natural birth can also have a big impact on the labour. Because women in the study were randomly allocated to either a caesarean or a vaginal delivery, mothers committed to a natural birth would have opted out.
"Women who wish to achieve natural childbirth [will] exclude themselves from a lucky dip," she says.
Banks's book and my own analysis of the data made me determined to attempt a natural birth. I searched for a public hospital in Sydney that had the skills and was willing to offer a planned breech delivery. There was none.
At the Royal Hospital for Women, midwife Tess Back had tried to soothe my distress with the comment that we "could always go to John Hunter". Trekking 170 kilometres up the Pacific Highway seemed extreme. But, compared with needing up to six weeks to recover from what we concluded was an unnecessary operation, it really wasn't that crazy.
Two days after the failed turning attempt we were in Newcastle meeting with Bisits. Four days later we made a temporary move north.
Bisits' approach to labour was key in our decision to go ahead with what many told us was a high-risk option. "The way you have the baby is important," Bisits says. "It's one of life's major events and therefore [the type of delivery] does matter, and to deny women the experience on the basis of one trial - that has to be subject to some scrutiny."
John Hunter has delivered more than 300 breech babies since 1998 and averages more than one breech birth a fortnight. The hospital delivers babies that are not too big or small and are in the frank breech position, that is, bottom-first, not feet-first. The mother's pelvis also needs to be of an adequate size.
Bisits prefers an active labour with the woman sitting on a horseshoe-shaped birthing stool for the delivery. The baby's heart rate is continuously monitored during labour and a pediatrician is on hand in case any complications arise after the birth. A caesarean will be performed if the labour does not progress steadily.
When Finn finally made his bottom-first entrance two weeks after we relocated to Newcastle, the labour was spectacularly uneventful. It began spontaneously and lasted just 12 hours, the first six of which were at our rented home. The six hours at the hospital progressed smoothly and, except for a small amount of gas, were drug-free.
Finn was a picture of perfect health with Apgar scores of eight one minute after the birth and nine five minutes after. Apgar evaluates the baby's heart rate, respiration, muscle tone, reflexes and colour and ranges from 0-10, with 10 being perfect.
Importantly for me, I was out and about with my son within a few days. I didn't need any painkillers to recover and I left the hospital after one night.
Caesareans have their place, but, as Bisits says, a woman's informed choice is also important. At John Hunter, four out of five women with breech babies will elect to have a caesarean, even though a vaginal delivery is offered.
"Even the women who have caesareans feel much better about their decision when they go through the whole process, rather than being told 'This is what you'll have to do'," Bisits says. "It becomes a much more positive experience."
VITAL STATISTICS
* Up to 4 per cent of babies will be breech at the end of the pregnancy.
* In 2005, 322 breech babies were born in NSW, down from 1187 in 1990 and 762 in 1999.
* This meant 0.4 per cent of babies born in NSW in 2005 were by vaginal breech, down from 1.4 per cent in 1990 and 0.9 per cent in 1999.
* John Hunter Hospital delivers more than one breech baby a fortnight.
* Three-quarters of vaginal breech deliveries at John Hunter are planned. Four out five women with breech babies at John Hunter elect to have a caesarean.
