Tuesday, October 20, 2009

International Breech Conference: Day 2 (The Germans)

Friday, October 16, 2009

My co-presenter and I hurried to arrive on time in the morning, because Dr. Frank Louwen was speaking about "Breech Delivery in the 21st Century." He is a German OB from Frankfurt who is doing breeches with the mother in a hands & knees position, rather than on her back. At the start of his presentation, he expressed thanks for being invited to this conference and hoped that it would help change minds. He commented that it's better for women to give birth in upright positions--but quite uncommon from obstetricians to acknowledge this.

When he first came to his hospital, no one had done vaginal breeches for 30 years. So first he had to convince his maternity unit to start doing breeches again. They did a pilot study of primip vs multip vaginal breeches and, so far, have found that primips do just as well.

He started with the story--which at some point will probably reach semi-mythological status!--of how he first thought of doing breech births upright. One day he had his obstetric textbook open to vaginal breech birth. He was on the phone, walking around, when he glanced at his book from the other side of the desk. He saw the woman giving birth turned 180 degrees--almost a picture-perfect of hands & knees birthing. He had an "aha!" moment. It's fairly common for women to give birth to vertex babies in Germany in upright positions, but not breeches. So the first thing was to see if any woman was willing to humor him. He approached one with a breech baby and said "I'd like to try this, but I've never done it before. Are you on board?" She said "sure! let's give it a go!" He didn't have to do any manipulations on the baby at all, and the birth turned out wonderfully. Several hundred upright breech births later, he's convinced that it's a much better way to birth a breech.

During his presentation, he showed slides and videos of women in his hospital birthing breeches on hands & knees. They were pretty mind-blowing. I've seen this sort of thing before, but only in home birth videos. To see women doing this in a hospital setting, with a kind, calm, supportive staff, was beautiful.

Upright breech births in his clinic are done with very few maneuvers, if any. Except for very unusual cases--for example, a trapped head or nuchal arms that don't resolve on their own--the only time they might touch the baby at all is to do "Frank's Nudge" or the "Louwen maneuver." If the body births but the head seems to need a bit of assistance, he presses in at the baby's shoulders well beneath the clavicle, which causes flexion of the head and the baby delivers. It appeared that he used very little pressure. The technique is to press the shoulders back toward the mother's symphysis pubis (which is behind the occiput) and this causes the head to flex. There is no downward traction and the technique is so fast it is hard to catch it on some of the videos until you know exactly what you're watching for.

He commented that it's great to see those nice, easy breech births that happen 80% of the time. But what about those scary situations that give breech birth a bad name? He then showed us videos of some very complicated breech births in H&K: nuchal arms, or the baby born to the umbilicus but then stuck there, despite strong maternal pushing efforts. And it was amazing to see how easily and gracefully he was able to resolve these complicated situations, with a minimum of manipulations (thanks to the maternal positioning). Remember stillbirth #1 from Day 1 of the conference--the baby in the TBT that was born to the umbilicus, then got stuck, so the doctor pushed the baby back up and did a c-section? Well, he showed us this same situation in his clinic, except with a few very gentle maneuvers he was able to deliver the baby vaginally. He remarked, "in the Hannah trial, this baby died."

A few other things from his presentation: he never does episiotomies with breeches (vigorous cheering and applause from the audience). You must keep your hands off the baby. No touching--it will just complicate things. And hands off the mother's bottom, unless she already has a laceration, at which point some gentle counterpressure might help her from tearing farther. I loved watching the videos, because they did a lot of touching--gentle, reassuring touch on the mother's back or legs. If the baby hasn't been born within 4 hours after the mother has reached complete dilation, they will move to cesarean section, since a prolonged pushing stage is a risk factor for vaginal breech birth. (This is more generous than the new Canadian guidelines. The SOGC notes that a passive stage between full dilation & pushing can last up to 90 minutes. Then, after the mother has been actively pushing for an hour and birth is not imminent, the SOGC recommends moving to cesarean.) Don't break the mother's amniotic sac--that offers the best possible protection for a breech baby.

Dr. Louwen has been studying the results of breech births in the hands & knees position and these are his preliminary findings (of over 300 births):
  • Hands & knees seems to reduces fetomaternal complications
  • Umbilical cord is less influenced by compression in stage II
  • Incidence of maneuvers is reduced, with less perinatal and maternal morbidity
He's working on planning a multicenter RCT of maternal position (hands & knees versus on-the-back) in vaginal breech birth and has invited interested midwives or physicians to participate. This, he hopes, will reveal the real complication rate of vaginal breech birth, when women are birthing in the best position for themselves and their babies.

I know this is already turning into a novel, but I also wanted to comment on Dr. Louwen's demeanor and personality. I would describe him as jovial, kind, and gentle. This comes from watching him speak, of course, but also from seeing him in action (or rather, non-action most of the time) in the birth videos. Being gentle, patient, and calm are intangible qualities, but probably just as important in the success of a birth than any newfangled method or technique.

After his fantastic presentation, his colleague Dr. Anka Reitter discussed whether prenatal pelvic MRI for primips can help reduce the incidence of emergency c-sections in vaginal breech births. Dr. Reitter was trained in the UK before the Hannah trial and saw lots of vaginal breech births. She has found that, in their unit, primips can birth breeches as well as multips. They also do vaginal breech births for primips with twins (one or both breech). If ECV is not successful, they offer MRI scans to primips or "functional primips" (i.e., a woman who has never had a vaginal birth before) with full-term breech babies and recommend surgical delivery for mothers with an obstetric conjugate of less than 12 cms (pretty sure it was the obstetric conjugate, but don't take that as gospel!). From their preliminary study, they've found that MRI for primips may help reduce the number of emergency cesareans during an attempted vaginal breech birth. She also cited some other breech studies currently underway. When comparing H&K to on-the-back positions, they found that H&K significantly shortens the 2nd stage (pushing). The average 2nd stage for H&K was less than an hour, while the average for on-the-back was twice as long!


  1. Wow! It is incredible to read the procedure that I used to deliver my girl! I didn't know any of this ahead of the delivery (in a German hospital with midwives). I wish they would have told me about this ahead of time if only so I had an image of it in my mind. I had informed them that I was interested in an unmediated, upright birth, and they were totally on board. However, I eventually laid on my side for about 45 minutes as I was falling asleep between contractions in my kneeling position (I almost fell over!). As the second stage came on, the midwife coached me for the transition to the delivery position, and just before the last few contractions, I turned onto my hands and knees, and the little girl just slipped out and fell onto the bed! I thought pushing would be the hardest part, but it was only two contractions. My mom took amazing photos of the birth and you can see the midwife's hand at the ready, but she never touched the baby until she was out.

    Now I know the whole background of that experience. Thanks for sharing!

  2. Re: epidurals and H&K - I have a friend who is a grand multip. and lives in Germany - she said (somewhat bitterly) that "they don't believe in epidurals over here." Maybe it is the case that most women in Germany either do not opt for them or are not offered them unless they are totally exhausted...I'd be curious to know what their rates are because my friend is a sample size of 1...

  3. Good question about epidural use in Germany. I seem to remember hearing one of the German physicians mentioning that women in their studies got epidurals if they requested them, but I could be totally wrong and remembering that from somewhere else!

  4. I wish all OB's were like Dr. Louwen.

  5. He sounds amazing and it is so great to rewad such sensible, logical, level headed stuff. Thank you as alwasy for your blogging, Rixa--still reading and caring, just been a really wierd patch for us...

  6. my sister did hands and knees with an epidural. her nurse suggested it and gave good support to help her hold the position. not a breech birth though.

  7. I love reading your posts and articles. I'm a bit of a natural birth junkie and love hearing encouraging and empowering stories.
    I have a question for you regarding shoulder distoscia's (don't think I spelled that right). I have had 2 natural births, and both of them my daughters shoulders got stuck, it seemed they never rotated properly. The second time it happened I was in a hands and knees position though slightly upright leaning into an inclined bed. I was wondering if you could give me any information as to the best way to deal with this if it happens again (I'm pregnant with my 4th baby and a little worried about it happening again). Could it be that I am pushing to urgently and not giving the baby enough time to rotate before the shoulders pass? Thank you so much for your time!

  8. I was fortunate to be able to attend the pre-conference workshop at which Dr. Louwen and Dr. Reitter spent a lot more time talking about what they do in Frankfurt (and showed a lot more video clips!)

    Many of the women do have epidurals, they are the so-called "walking epidurals" and they generally let them wear off somewhat for pushing. It doesn't seem to effect the ability to use hands-and-knees position; I (and several of the other midwives there) felt that the narrow hospital beds would be more of an impediment. They do continuous fetal monitoring and one of their fndings is that hands-and-knees significantly reduces CTG abnormalities, probably due to reduced pressure on the cord.

    "Frank's nudge" is actually Betty-Ann Davis' coinage for what Dr. L modestly calls the "new maneuver." Dr. Reitter referred to it once as the "Louwen maneuver" and Betty-Ann corrected her but I think "Louwen maneuver" is what will be known to obstetrical history -- it sounds much more medical, which is probably why Betty-Ann prefers "Frank's nudge," and is also very catchy (Louwen is pronounced Loo-ven and so there's almost a rhyme there.) Rather than causing a slouch, the technique is to press the shoulders back toward the mother's symphysis pubis (which is behind the occiput) and this causes the head to flex. There is no downward traction and the technique is so fast it is hard to catch it on some of the videos until you know exactly what you're watching for.

    They do risk out a fair number of women before labor, and others choose planned c-section, but when I asked at the pre-conference workshop how many cesareans they do after labor has begun, I was told they have about an 80% success rate with vaginal breech birth -- quite impressive. The two "complicated" clips he showed with the full set of Loveset maneuvers for extended arms were the ONLY two times he has had to do that in over 300 hands-and-knees breech deliveries, he noted how fortunate it was that he got both of them on video. :-)

    Your point about the "intangible qualities" necessary for success is very important to note; and how much depends on the emotions and attitude of the doctor or midwife who is present in the birth space. I think the phrase Dr. Louwen repeated most often, both at the pre-conference workshop and at his briefer conference presentation, was "Do not be anxious!" Hopefully everyone there took this to heart.

  9. Thanks Sora for clarifying the maneuver, I was just skimming the responses before I wrote the same thing. I'd also like to clarify that the position that they use is knee-elbow and not hands and knees.

  10. Please also note that the actual maneuver is not "he'll gently grasp each shoulder between his thumb and fingers and make the baby's shoulder's slouch inwards, similar to how you'd slouch your shoulders."

    In actuality he doesn't grasp at all, just presses in at the shoulders well beneath the clavicle, which causes flexion of the head and the baby delivers. It appeared that he used very little pressure.

  11. Thanks for the corrections. Someone at the conference had demonstrated the slouching thing to me, but I guess they were wrong too! I'll change the original description in the post.

  12. I thought I saw a combination of knee-elbow and hands and knees. Some of the women were definitely H&K in the clips we saw on Friday, at least in certain parts of the births. In any case, I don't think there's a huge degree of difference between the two.

    Any other thoughts/corrections/additions, especially from people who were at the pre-conference workshop?

  13. I can't give any stats on the rates of epidurals in Germany, but from the many birth stories I have heard from friends over here, you better ask for it ahead of time because they will refuse after a certain point. I think they wait for a woman to request it rather than take its use as a given. They seem to be pretty hands-off in general during labor and some American friends felt a bit lost as there was no guidance.

    I had done a lot of research before my daughter's birth, so I had things that I wanted to try. The midwife basically only made her presence known to examine me a few times and when I needed some support with the pain. She basically sat back and offered calm energy. When the second stage came on, she was right there to help me slow things down a bit (it was over in about 15 minutes) and guided me to the hands and knees position. No epidural was suggested at any point.

  14. WOW thank you so much for all of this!! I have never had the opportunity to attend confrences and am a newly licensed midwife. This info is great and has really sparked a desire in me to learn more about breech birth... it's really such a shame that it is being lost!!

  15. Do you (or anyone else) know how to get a hold of Dr. Louwen? An email or ? I would really love to ask him some questions. I wish he had some video footage available online somewhere!


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