Transcript typed by yours truly.
All In A Day: Breech Births
Alan Neal: A couple times on “All In A Day” we’ve checked in with a group called the Coalition for Breech Birth. This coalition advocates for the natural delivery of babies who are in the breech, or bottom-first, position. The Society of Obstetricians & Gynaecologists [of Canada] reversed it position on breech deliveries last year. They now say it’s safe to deliver breech births naturally in most cases. But a lot of obstetricians aren’t trained in delivering breeches because for years, doctors have been directed to do C-sections instead. Well, this is all slowly changing at Ottawa hospitals. The Montfort Hospital has been delivering natural breech births over the past year, and just recently, the general campus of the Ottawa Hospital started joining in as well.
Dr. Glenn Posner is an obstetrician/gynaecologist who’s been trying out his new skills in natural breech delivery. And Robin Guy is the co-founder of the Coalition for Breech Birth. Both join me on the phone. Hello there.
Dr. Glenn Posner: Hi.
Robin Guy: Hi. How are you?
Alan Neal: I’m fine. Dr. Posner, I’m going to start with you. Take me back to med school. What kind of training did you actually receive during your residency when it came to breech births?
Dr. Glenn Posner: Right. So I graduated from med school in 1999 and started my residency in Ottawa just as Mary Hannah’s trial was being stopped early because they found that there was more risk in the trial of labour group. So basically my welcome to residency in Ottawa was: no more breech deliveries vaginally. So my cohort of residents—we started training about 11 years ago—are, I’ve been saying, the worst-trained obstetricians in Canada!
Alan Neal: So no one knew how to do the breech births.
Dr. Glenn Posner: Right. We practiced our skills at cesarean section, we practiced on simulated models, but there’s nothing like real hands-on experience. We practiced with second twins that are still acceptable to be delivered breech. We never really got to see a planned trial of labour for breech.
Alan Neal: Can you just remind us why this was the policy?
Dr. Glenn Posner: We try, as much as we can, to practice evidence-based medicine. There was a trial that was published in the Lancet in 2000 that said that babies that were born by elective, planned cesarean section did better, had less problems, than babies that were born when a trial of labour was planned.
Alan Neal: So then the SOGC changes its recommendations, saying it’s okay to deliver breech babies naturally. What happened for you then?
Dr. Glenn Posner: [laughs] Right. So I did 5 years of residency. I had practiced at Montfort for 5 years. I started working at the General last year, and they tell us that now it’s okay. Well that’s all fine and dandy, but in my group of 12 obstetricians, there’s only 9 of us who actually are trained to do it. So what happens when somebody comes in in labor on my shift? I want to provide a safe experience to anybody who comes in when I’m working.
Alan Neal: So what did you decide to do at the Ottawa hospital?
Dr. Glenn Posner: My group has got together and decided that if somebody comes in when I’m on call, I’ll do my best to find one of the veterans to come in and supervise me. And if they’re on call, they’ll call me in to come and watch them. And that way, over the next few years, my experience will kind of get up to speed.
Alan Neal: But are the veterans you’re talking about—are they particularly familiar with breech birth?
Dr. Glenn Posner: Well you know, all you need to do is a few difficult cases and to be able to get yourself out of trouble a few times. There are certain techniques and maneuvers, certain forceps that we use. All you really have to do is to see that in action a couple of times. I’ve done a few breech deliveries now, and they both went really, really smoothly. That’s not actually educational for me! [laughs]
Alan Neal: Yeah. You kind of need the complications.
Dr. Glenn Posner: To be a real obstetrician, you really have to be able to get yourself out of a tight corner.
Alan Neal: When you’re doing the birth simulation, then…
Dr. Glenn Posner: Yeah, I actually teach residents how to do breech deliveries. I can teach somebody the theory. I can teach somebody the maneuvers. We have all these fancy names that we call when we try to make sure the arms come out okay, and what we should do, and how to put on these forceps. But it’s totally different when it’s a real person whose baby’s head is trapped, that you have to actually ask for that pair of forceps, and actually put them on a real person. Your adrenaline level is completely different than at the simulator.
Alan Neal: Of course. So you attended a birth last week.
Dr. Glenn Posner: Yeah.
Alan Neal: What was it like to deliver a breech baby?
Dr. Glenn Posner: That was the second one. What made this one really interesting was that we’re trying a new position, where mom is actually on all fours. And it was absolutely amazing. It went great, and I was very, very that my colleague, Dr. Geneviève Rousseau, came in from home on her day off to watch me do this delivery and to be there for me in case I ran into trouble. And that’s why I was calm during the delivery, because she was there next to me.
Alan Neal: Can you describe what this was like, what that process is? So the mother’s on all fours…
Dr. Glenn Posner: It was crazy. So mom’s on all fours. I could tell by watching her body language that it was imminent. We went to go prepare the operating room. I went and put on a pair of gloves in case we didn’t make it to the operating room. What makes the story even funnier is that Betty-Anne Daviss, the midwife who was helping with this, had just shown me a video from the German experience not 10 minutes earlier. There I am: everybody has left the room to set up the operating room. The next thing you know, the nurse is yelling for me that the baby’s coming out. I come back into the room, and it looks exactly like the video did 10 minutes earlier!
Alan Neal: So hopefully you were paying attention to those 10 minutes!
Dr. Glenn Posner: I was. This baby is hanging there. Imagine—the bum is out, the legs are folded up, the feet are still inside mom, the head is still inside mom. The baby’s folded in half and just dangling there. And obstetricians really like doing things. We want to help out. But the video said: don’t do anything, just watch and be ready to help out. I’m just poised there between mom’s legs, waiting for this baby to fall out. Then Betty-Anne ran back, and Dr. Rousseau ran back. They’re all talking me through this thing. And there was actually nothing to do! It happened beautifully, exactly like the video. The feet popped out, and then we did this tiny little maneuver [likely the Louwen maneuver] to help out with the shulders, and then the hands came out, and then the head came out.
Alan Neal: What is it like waiting? What is that moment like?
Dr. Glenn Posner: You know what, this one wasn’t as bad as the first one I did. With the first one, the patient had an epidural, so it took even longer. It’s very hard for an obstetrician to wait. But this one went fairly quickly and afterwards, we’re all on this adrenaline high that this delivery took place and everything went well. I’m feeling bad for all the people that I’ve sectioned over the last 11 years! My own wife had a cesarean section for breech for our second baby, and our second baby would have come out, probably, no problem also.
Alan Neal: I’m going to get back to you in just a moment. But Robin, I was wondering what these new practices at the hospital mean for your group. You’ve got doctors who are now training and wanting to find out how to do this.
Robin Guy: Well, you know what’s really exciting about this is not just that we’re starting to see vaginal breech births happen more frequently, but that we’re seeing an openness to a change in practice. It has been traditional in North America for women to have been, like it or not, placed on their backs, which actually causes some problems. It increases the likelihood of cord compression during a breech birth. Putting the mom on all fours—we’ve got early data from a group in Germany who made these videos that this [all fours position] is actually a real significant increased safety for the mother and the baby. So to see this adopted and to see the collaboration with a midwife. We don’t like it, but there is professional snobbery. There are women everywhere who are cheering for Glenn Posner, who wasn’t afraid to take advice from a midwife. We’re cheering for you Glenn; we love you!
Alan Neal: And the fact that he paid attention to the video, too, that she showed him 10 minutes earlier.
Robin Guy: Yeah. We are actually seeing real collaboration obstetricians and midwives and other professionals, working towards real patient care. And that is extremely exciting for women who have been frustrated by a lack of collaboration.
Alan Neal: Dr. Posner, you mentioned that you were waiting for births that would have more complications to them in order to learn better. What are some of those complications?
Dr. Glenn Posner: Well, when it comes right down to it, the head can get stuck. The whole body is out and the head is still in. If the head is too big to come out that way, then you’re in trouble. We have maneuvers to try to prevent that from happening, and ways to hold the baby, and not to pull on the baby, and then we have a special set of forceps, and where your assistant is supposed to push on the abdomen. The other complications is, if you do pull on the baby, the baby’s arms can actually get stuck behind the neck and make it more difficult for everything to come out.
Alan Neal: What do you do in that situation?
Dr. Glenn Posner: Well, you shouldn’t have been pulling on the baby to begin with, is what they tell me. But we have maneuvers. Like everything in medicine, they all have names, named after somebody who has invented them. We go through our maneuvers. But the two that I’ve seen were so easy, I really feel like—I don’t know—I’ll have to see 5, 10 nice breech deliveries before I stop calling my partners in from home to help me out, or I stop coming in from home to watch my colleagues do it.
Robin Guy: If I can add for just a second, this group in Germany who has been pioneering the hands & knees position in the hospital, they’ve been doing this for 5 years and 400 births. And they have not had to use forceps to get a baby out. Not once.
Dr. Glenn Posner: That’s great to hear.
Robin Guy: So it’s a big change in practice, if we can convince—we’re trying to get a randomized controlled trial going internationally examining the difference between delivering a breech baby with a woman on her back and delivering a baby on all fours, so we can actually quantify the difference. Having some data there would make a real difference for a lot of people.
Dr. Glenn Posner: Yeah.
Alan Neal: That, Dr. Posner, what Robin’s just saying there, that need for data: is that what you’re hearing from a lot of your colleagues as well?
Dr. Glenn Posner: Yeah. I find that really reassuring. If they did that many deliveries and never had to pull out the Piper forceps, that makes me really happy. Because I do not want to put on a pair. If I had to put on a pair of Piper forceps tonight to save the baby, my coronary arteries would be squeezing a little too hard.
Alan Neal: Are there colleagues who are still saying, “well, we don’t want to do it”?
Dr. Glenn Posner: I think that if we do more of this, and it becomes the standard of care again, people just want to practice safely. We all want the same thing. We really do. Obstetricians sometimes get a bad rap for doing a lot of cesareans, but at the end of the day, we want healthy moms and healthy babies by whatever means necessary. Do I do more cesareans, personally, than some of my colleagues who are really good with forceps? I probably do, but I deliver safe babies. And if I do a couple extra cesareans a year than some of the others, I can live with that because I deliver healthy babies. So sure, there are going to be places in town that are more reluctant to do it. Some obstetricians would be more reluctant. And we’re still going to be doing a lot of cesareans. There are a lot of people who are not going to qualify for the perfect breech delivery that we’ve stipulated. We’re still going to be doing a lot of cesareans, but at least in ideal circumstances--especially when people have had babies before vaginally, with good-size babies, who are having good labours--if we can avoid a few more cesareans, that would be great.
Alan Neal: Dr. Glenn Posner, Robin Guy, thanks for being with us.
Robin Guy: Thank you, Alan. Thanks for the attention to the issue.
Dr. Glenn Posner: Thanks.
Alan Neal: Goodbye. Dr. Glenn Posner is an obstetrician/gynaecologist at the General campus of the Ottawa hospital. Robin Guy, the co-founder of the Coalition for Breech Birth.