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!