Thursday, October 15, 2009:
Dr. Andre B. Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada (SOGC) since 1991. He discussed how we came to the current approach to breech birth. I don't have notes on this presentation so I can't give much more specifics (they're all running together in my head at this point).
Dr. Marek Glezerman spoke about "How to Save a Vanishing Obstetric Skill: Vaginal Breech Delivery." He emphasized the immense challenge in bringing back vaginal breech birth, since with the deskilling of obstetricians and residents, it will take a long time and a lot of births for physicians to re-gain the appropriate skills and volume of births. He spoke of the importance of simulation training for breech birth; since opportunities to witness and assist at "real" vaginal breech births are fairly scarce, simulation training can help birth attendants gain the necessary skills and practice in order to keep calm and know what to do. He also explained the weaknesses and flaws of the Hannah Term Breech Trial.
Betty-Anne Daviss, an Ontario midwife, researcher, and professor at Carleton University, gave an entertaining presentation about "Choosing the Myths and Fears We Live By"--part scatterbrained comedy, part sound & light show (complete with a gigantic pelvis & Homer Simpson "baby" doll sitting breech in said pelvis), and part call to arms. She challenged the SOGC's position that breech birth is best conducted in a hospital setting. She spoke of the 4 "Ps": Pelvis, Passenger, Power, and Psyche. She noted that in Europe, obstetricians tend to focus on the pelvis. MRI scans of the pelvis are fairly common there, whereas they're rarely done over here. North American obstetrics places most emphasis on the passenger: estimating the baby's weight on ultrasound, intervening for suspected fetal macrosomia, etc.
So what did she say about breech specifically? Quite a bit, so I'll try to cover the main points.
- She first learned about breech in upright positions decades ago from Guatemalan midwives.
- She has traveled to many European countries to learn about breech birth and found that many medical centers there declined to participate in the Term Breech Trial because the study's protocols did not match their evidence for successful vaginal breech birth.
- She is quite skilled in vaginal breech birth and recently attended 20 vaginal breech births with Dr. Frank Louwen in Frankfurt (who was the "star" of this conference with his research on the hands & knees position for vaginal breech birth).
- She noted that it has traditionally been--and still is--very hard for obstetricians to listen to midwives. Midwives, for example, have been doing breech births in upright positions for, well, probably as long as midwives have been around! And they've published and spoken about it in the Western world for the past two decades or so (Mary Cronk, Jane Evans, Maggie Banks, etc). But--and these are my observations here, not her words--it wasn't until a German OB began doing upright breech births in a medical center that other doctors paid notice.
- Despite the de-skilling of midwives and physicians in vaginal breech birth, mothers themselves have never been de-skilled. Their bodies still know how to give birth to breech babies.
Her comments led me to wonder if the so-called divide between technology and intuition (you know, the discourse of "artificial/natural") is really a false distinction. I love how she melded the use of technology with indefinable, intuitive, hands-on skills.
After lunch, we had a choice of five different breakout sessions. I went to Michael Hall's presentation "Breech Vaginal Delivery: Tips, Tricks, Techniques." He's an older OB near Boulder, Colorado and has always done vaginal breech birth, in large part because of continued demand for his skills within his community. He remarked the Boulder is a particularly progressive community, with large numbers of doulas, midwives, and educated women who demand options. He trained in Oregon, where he says he learned how to do normal vaginal births with a midwife. He's also married to a hospital-based CNM. He's well known as a breech-friendly doctor, so most of the breeches in his area get funneled down to him. Which is great, because doing 20-30 breeches a year keeps his skills intact.
I had to laugh when he prefaced his presentation, almost apologetically, with the caveat that this was the "traditional" way of doing breeches (i.e., the woman on her back with legs up in stirrups), since that was the way he was taught. He mentioned the new way of doing breech births on hands & knees. My paraphrase: "well, this is the old way of doing vaginal breech, since that's what I know, but we'll be learning all about the new way tomorrow."
Dr. Hall's criteria for vaginal breech birth include: EFW between 2000-3500 grams, frank or complete breech, pelvimetry to determine an adequate pelvis (he emphasized that it's extremely rare to come across a contracted pelvis), flexed head, progressive labor loosely aligning with Friedman's curve, normal fetal monitoring with good variability (so I assume that means cEFM), an experienced operator with good forceps skills, and true informed consent. He emphasized that there is always room for flexibility in these criteria and that it's important, as a provider, to trust your instincts and to respect your own comfort zone.
So I'll walk you, very briefly, through the mechanics of how he does VBB. The mother pushes the baby out on her own with no traction or episiotomy, until the baby is out to the umbilicus. Dr. Hall rarely does episiotomies and, in those rare occasions, never when the baby is rumping or coming out to the umbilicus; if you do an episiotomy at those points, it will just create more problems. He kept emphasizing over and over: don't touch the baby, keep your hands off and be patient. When the mom is on her back, you'll see the baby come out, back up, almost straight upwards. The legs will fall out on their own if you're patient. If the baby comes out to the side, rather than back up, that means it has a nuchal arm. If the arms do not emerge spontaneously, he gently releases the anterior arm, rotate the baby, and release the other arm. At this point he papooses the baby's body in a warm towel and holds it slightly elevated. The last step is to gently push down on the perineum (i.e., with your fingers inside the vagina, pushing down towards the rectum) and the head will release as he guides the baby's body following the pelvic curve. 99% of breeches will come out with no further assistance. Low 1-minute Apgars may be common; just be patient and let the baby get its blood (which means the cord needs to stay intact) and it will perk up. You also need to train your nursing/pediatric staff to be patient, as they'll want to get their hands on the baby, while it just needs some time and a nice pulsing cord!
If the head is truly stuck, Piper forceps may be needed (he has used them 3 times in 30 years). The application and traction should be easy, with no resistance. If it's hard to do, then you're not doing it right! Dr. Hall lamented on the lack of forceps training among new OBs. Many OB residents are only trained to use a vacuum, which of course isn't of any use for a breech baby.
Dr. Hall's hospital recently made him start doing all vaginal breech births in the OR--mostly a push from anesthesia--which he doesn't like because, in his experience, you'll have plenty of warning that a c-section is necessary with a breech baby. If the baby is out halfway and is stuck, you can't do a c-section at that point anyway. (In the next presentation, Dr. Menticoglou gave an example of one physician who did just that, with disastrous results.)
Dr. Hall sees vaginal breech birth as an art: you have to be facile with your fingers, maintain humility, and keep from getting overly excited. That means someone in the room needs to maintain a quiet, calm atmosphere. Sometimes he'll send an overly anxious nurse or pediatrician "to get the Piper's forceps" but really it's just to get them out of the room! He concluded his presentation with strong support for simulation training for vaginal breech birth.
One thing that made me laugh was his hands-on demonstration of the mechanics of breech birth, using Betty-Anne's oversized pelvis and Homer Simpson doll!
After that interesting breakout session (sadly, I missed Lisa Barrett's presentation on "The Physiological Face of Breech Birth" because it was at the same time), we listened to Dr. Savas Menticoglou talk about "The Term Breech Trial: Perspectives from participating units." He reviewed the initial and 2-year followup data from the Hannah trial, as well as several commentaries (Keirse, Glezerman, Kotaska, etc). He analyzed all of the deaths reported in the TBT, especially those within developed countries. For example, there were 3 reported stillbirths. In stillbirth #1 (Canada), a primip was induced at 41+5. She had an epidural and pushed the baby out to the umbilicus, but could not get the baby out any farther. At that point, the attending physician made no efforts to do traction or any kind of assisted breech delivery/extraction--instead, the physician pushed the baby back into the uterus and performed a cesarean. The baby was dead by time the surgery was done. Stillbirth #2 was twins (and should not have been included, since this was a study on singletons) and, if I remember correctly, the first twin was a very small baby, quite macerated, and breech. Stillbirth #3 took place in Romania, where they could not do a cesarean within 10-20 minutes as per the Hannah requirements. It was a primip who went into spontaneous labor at 41 weeks with a frank breech. For the last 20 minutes of pushing (48 minutes total), the attendant could find no heart tones and they did not know if the baby was alive or dead until it was born.
Okay, sorry for all these gory details but he used these examples to show how, in all 3 cases of stillbirth from the TBT, they should not have been included because they all violated one or more Hannah protocols, particularly the one calling for experienced, skilled physicians prepared to deal with breech births.
Next, he spoke about other recent studies of breech births from different European countries, including the PREMODA study from France and Belgium. Finally, he discussed the process of coming to the 2009 SOGC Breech Birth Guidelines and the various committees it had to go through. There were 10 physicians working together to come up with the new guidelines, coming from widely varying perspectives. Some felt that VBB was quite safe, while others felt strongly the other way.
Finally, he reviewed some of the historical literature and statistics on breech birth, trying to figure out the intrinsic risk of vaginal breech birth. He also had some fascinating commentary about our cultural expectation of perfection: if we want to believe that no "normal" baby should ever die or be damaged during labor, we are going to have to accept an extremely high cesarean rate.
The next presentation was a delight after the more somber, numerical approach of Dr. Menticoglou. We listened to Jane Evans, a British midwife, talk about the "Mechanisms of Spontaneous Vaginal Breech Birth." Of all of the midwives' presentations I attended, hers was the most compelling, most eloquent, and most adept at addressing the very wide range of attendees (OBs, medical students, nurses, midwives, doulas, and lots of parents). She defined spontaneous breech birth from a midwifery perspective: spontaneous onset of labor, no induction or augmentation, labor progresses smoothly (contractions become longer, stronger, and closer together), the presenting part is accompanied with dilation of the cervix, and, in second stage, the expulsive efforts of the mother, together with the baby's movements, result in the baby being born without traction or manipulation from the attending practitioner. She stressed that women have been delivering their babies in upright positions since, well, forever, until we started interfering in the last few hundred years.
Jane Evan's presentation covered the mechanism for how the baby negotiates the pelvis in a breech presentation. She used a life-size pelvis and doll to illustrate, step by step, along with videos and pictures of women birthing breech babies in upright, hands & knees positions. It was fascinating to learn how the baby rotates through the pelvis, step by step, with each movement optimizing the shape of its body with the shape of the pelvis. I won't go into too much detail with each of the intricate movements through the pelvis, but there were a few lovely phrases that I just have to mention.
- "The pelvic floor is a lovely, beautiful valley”: said as the presenting part hits the pelvic floor and begins rotating
- "Rumping": the term for when the breech baby appears at the perineum ("crowning" for a vertex baby)
- "Oozy births": Jane Evans mentioned that you'll likely see lots of baby meconium and possibly some maternal poop as well. Don't wipe anything, because you don't want to trigger the mother's anal sphincter to close at the moment when she's pushing out her baby. Also used to describe how the baby's body often oozes out of the mother's vagina.
One comment I found particularly interesting, given my academic and personal interest in unassisted birth, was that if we require all women to have cesareans for breech presentation, "patients who refuse cesarean may give birth at home unsafely and unattended." This is theme that kept cropping up. I am glad that unassisted birth has made it on the Canadian obstetrical radar. While I am hesitant to make any blanket statements about the safety of unassisted birth, I strongly feel that no one should make that choice because of a lack of options.
Another poignant comment was that some women will refuse a cesarean, no matter what the official policy or guidelines are. "Should we abandon these women?" he asked. The answer is no, and the new SOGC guidelines stress in several points that women who refuse a recommended cesarean should not be abandoned or coerced, but rather should receive the very best care in accordance with their stated preferences.
The absolute best thing of the day, I think, was one of Dr. Gagnon's very first remarks. He thanked Jane Evans for her presentation and said something to this extent: "after seeing her presentation, I finally understand why the upright position for breech makes so much sense! I am excited to go back to my hospital and start doing breech births on hands & knees." He was visibly enthusiastic about this new way of doing breeches. It was wonderful to see an OB so convinced by a midwife! Of course, the fact that upright breech births are now being done by an OB in a medical center had a lot to do with the reception of this "new" approach.