First Amsterdam Breech Conference, Day 2
Ken Johnson & Betty-Anne Daviss
Rethinking the Physiology of Breech Birth:
A Cohort Study in Frankfurt, Germany, 2004-2011
Betty-Anne Daviss opened the session by remarking that this study has been a study a long time coming; she’s been working on it since 2008. It is a collaboration between Frankfurt and Ottawa involving Frank Louwen, Anke Reitter, herself, her epidemiologist husband Ken Johnson.
When Betty-Anne and Ken spoke in July 2016, the manuscript had not yet been published. It is now available in the International Journal of Gynecology & Obstetrics: Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. If you scroll down to "Supporting Information," you will find additional tables and a video showing a H&K breech birth at the Frankfurt clinic.
Research over the last several decades has focused largely on comparison between vaginal birth and cesarean birth, and almost no focus on how to improve vaginal breech birth. She finds that sad. Most of the large registry studies (such as the ones done in the Netherlands, Canada, or Australia) appear to have a higher neonatal mortality and morbidity with VBB than with ECS. In Canada, when the authors presented the registry study, they said there was higher neonatal mortality & morbidity with vaginal breech birth. What they failed to say was that it was a composite variable. When they went to the actual table, the NNM was 0 and the morbidity was temporary, as in the Term Breech Trial. But if you look at the abstract, you get terribly fearful of vaginal breech birth, and that fear is difficult to undo.
Betty-Anne suggested suggested that we look at cohort studies done in units, like in Belgium, Dublin, and Frankfurt. In all of these places--with skilled attendants, good screening, and protocols--almost invariably the difference in NNM is very negligible.
Today she and Ken are presenting what it looks like to compare two kinds of vaginal birth. It wasn’t an intention-to-treat study; rather, it com compares what actually happened.
Next, Ken presented some information on the premature breeches, which wecluded from the study, but interesting nevertheless. The Frankfurt study included 750 term breeches. 42% were scheduled cesareans, half of which were by the mother’s choice. The Frankfurt cohort had a high number of primips. Most of the vaginal breech births ended with the mothers upright. They also looked just at last 2.5 years at the clinic, since they were almost exclusively doing upright births at that point. With mothers exclusively upright, they saw slightly higher success rates.
BAD: This is observational cohort study, not a randomized controlled trial. They are looking at what is, not at what’s planned and then what happens. Observational data in a unit is very useful and has some merit of itself that is better than randomization. But it does raise the question: how do people decide what position they end up in?
KJ: Having a woman upright resulted in fewer maneuvers. Forceps and episiotomies were never needed in any of the vaginal breech births.
BAD: They didn’t collect info about fundal pressure in the database, so it didn’t come into the survey.
KJ: Upright maternal positioning resulted in fewer neonatal injuries and a shorter 2nd stage of labor. How do they define 2nd stage in Germany? It starts at full dilation--not at the onset of spontaneous maternal pushing--so it includes a latent stage. This explains some of the longer stages recorded in the Frankfurt study.
The Frankfurt study used the definitions of fetal and neonatal mortality & morbidity in the PREMODA study. This gives allows them to compare the Frankfurt data to the PREMODA study and to the TBT (upon which PREMODA was based).
BAD: This database is incredibly useful. We need to have more of these databases to amplify this area of knowledge. Observational data in cohort studies is really valuable. Collect your data in your unit!
( I had to leave right as they started the Q&A)