Saturday, December 29, 2012

Birth options and recommendations in the D.C. area

A blog reader recently asked me for recommendations for providers and birth locations in the Washington D.C. area. She lives in Falls Church, VA and is open to considering all of her options, from home to birth centers to hospitals. She had her first children with epidurals and would really like to have her next baby unmedicated (although she's a bit nervous about how she's going to do it!).

Please add your recommendations in the comments or, if you'd like to keep things more private, via email.

Thanks so much!


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Monday, December 24, 2012

Pregnancy: Month 5

November was filled with breech-related activities: planning a vaginal breech and ECV workshop for next June, preparing my presentation "Connecting the Dots: The Future of Birth Advocacy," attending the 3rd International Breech Conference in D.C., and writing up summaries of the conference sessions.

In honor of breech babies and breech-friendly providers, I created this quilt block to represent my fifth month of pregnancy. It's the logo of the Coalition for Breech Birth and is simply named "Breech." 


I didn't have any cobalt blue fabric, but this deep purple linen was close enough to evoke the same feel.

I love the design of this logo. It captures the deep love and connection mothers have with their babies and the desire to protect and nurture their little ones, born or unborn. We have to keep this in mind when we talk about breech birth and about what options are "safe" or "acceptable."

~ Soapbox over ~

I hope you're having a wonderful time preparing for Christmas or whatever other holidays you celebrate. Our house smells of lebkuchen (German spice cookies) and caramelized onions (for tonight's French onion soup) and fresh paint (yes, I've been busy repainting before this baby arrives). We have a houseful of family and have more arriving on Wednesday.
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Wednesday, December 19, 2012

Pregnancy: Month 4

I first started feeling movement at 11 weeks. It began with faint flutters and bubbles, the kind that you're pretty sure are baby...but not entirely. By 15-16 weeks, it was definite. At this time, it really felt like a fish flopping around inside me. If you've ever held a live fish in your hands--something the size of a sunfish or crappie--you'll know what I'm trying to describe.

So this quilt block for the  fourth month of pregnancy reflects the sensations of movement. I named it "Quickening."

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Monday, December 17, 2012

Christmas wish list

I'd love to get a female pelvis model and cloth doll to practice & study the cardinal movements. Anyone selling a spare set? What suppliers sell the best cloth dolls?



A good portrait lens with a low aperture setting (1.4 or 1.8). This one would work with my  camera. I like bokeh!
The book Making More Plants



A Yepp Mini bike seat. It mounts on the front of the bike, right on the handlebar stem.


And this GMG Junior bike seat for the back of one of our bikes Too bad it isn't sold in the US! Maybe a Dutch reader could help me buy & ship a used one? They are everywhere in The Netherlands. I'd probably need the adapter too.


The WeeRide Co-Pilot bike trailer looks like fun!

I'd like to watch the documentary Catching Babies.


What's on your wish list? 
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Saturday, December 15, 2012

26 weeks pregnant

My weekly pregnancy silhouette has turned into a biweekly one! The weeks go by too quickly to get a picture taken every time.


Inga at 28 weeks
Dio at 26 weeks
Zari at 27 weeks (25 weeks gestation)

Now some details for those of you who care:

I've been measuring ahead for as long as I could take reasonably reliable measurements. There was some uncertainty about dates initially, but it was in the other direction (i.e., possibly being 22 weeks at this point rather than 26). With my 3 other pregnancies, I have always measured spot-on for dates, no matter how much or little I was showing. So here are some figures from this pregnancy:
  • 18 weeks: fundus at umbilicus
  • 21.3 weeks: 25 cms
  • 24 weeks: 27/28 cms (I sometimes measure twice, keeping my eyes closed so I'm not "cheating")
  • 26 weeks: 31/32 cms
This is making me go "hmmmmm....is there just one baby in there or two?" I have my next prenatal visit on Monday and we'll discuss possible causes. I'm not opposed to having an ultrasound if there's a sound reason.

Everything else is looking good. Weight gain is similar to other pregnancies (+14 lbs). Blood pressure is nice and low. Baby is nice and active. I've been sleeping reasonably well and hope that trend continues.
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Thursday, December 13, 2012

Tenure! (and something fun to read)

Eric just had his tenure review meeting yesterday...and he passed! We are so thankful for job security in this era of economic uncertainty.

Are any of you subscribers to the Journal of Perinatal Education? You might have seen Eric's essay "Freebirth" in the most recent issue (Volume 21, Number 4, 2012, pp. 202-205). It's worth the read :)
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Sunday, December 09, 2012

Complicated Breech Scenarios: Heads Up! Breech Conference

Day 3

Breech Birth Scenarios
Diane Goslin

Diane Goslin, who serves a large Amish & Mennonite population in Pennsylvania, described several complicated breech scenarios she has encountered. Gail Tully helped by illustrating the situations with a doll & pelvis. Diane then invited conference participants to share their own less-than-textbook breech births--this included footling and kneeling presentations, slow labors, long second stages, babies that did not rotate to anterior, and nuchal arms.

After learning from Jane Evans the signs of a normal, physiological breech birth, it was very enlightening to learn how to recognize and respond to abnormal breech situations. After all, that's really what breech attendants really need to know. Much of the time, breech babies emerge on their own. But what if they don't? That's when a cool head, skilled hands, and the ability to think on your feet can be lifesaving.

The main things Goslin has learned over the years:
  • A lot of patience and a lot of monitoring. A breech is not the kind of birth where you go sleep on the couch. You need enough help in case the mom, dad, or midwives are exhausted. 
  • Be able to picture your baby well and visualize how it's inside the mother. Become confident and competent with how the baby is positioned inside the pelvis. 
  • Think outside the box. As much as we might love H&K, for example, we have to be willing to try whatever works to help get the baby out.  
  • You have to be flexible and  see what's working. You can't just have one formula for getting these babies out. We don't like doing manipulations, but it there is trouble, it's better than a brain-damaged or dead baby. You need to know the maneuvers and know when & how to do them.


Jane Evans commented that British midwife Mary Cronk taught her a lesson about getting a stuck object out. Mary had a messy kitchen drawer that would often get stuck because some object was wedged and in the way. Mary's husband would shut the drawer a bit, wiggle the objects around, and then open the drawer easily. The same goes with breech birth. If you can resolve the obstruction, then the baby can descend easily.
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Friday, December 07, 2012

Pregnancy: Month 3

I hit a rough patch between the 5th and 11th weeks of pregnancy. The usual suspects--constant queasiness, no appetite, extreme fatigue, dizziness. I've never actually thrown up in early pregnancy; I just feel nauseated the whole time. Each pregnancy has gotten successively worse with its "morning sickness" symptoms. (Whoever decided to call it morning sickness anyway? Mine is all day and all night, and if anything gets progressively worse as the day goes on.)

The challenge for this quilt block was how to depict the third month of pregnancy. How do you visually represent exhaustion or queasiness? I thought and thought. I googled various search terms in conjunction with "quilt" or "block" but found no inspiration.

Finally, I decided to represent not the exhaustion or nausea, but what helped me get through it: reading books. As long as I was reading, I could ignore how icky I was feeling. So as soon as Eric came home, I would lie down, grab a book, and check out for the rest of the day. (And I did my share of reading during the day, too, while the kids were playing.)

I named this quilt block "Saved By The Books."

ps--some of you Second Womb Slings customers might recognize your sling fabrics :)


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Wednesday, December 05, 2012

Boob Hell: A book review

I've never been to boob hell. Not really even to boob purgatory, except for the plugged ducts I kept getting when Zari was around 4 months old. My experience with breastfeeding has ranged from mostly boob Omaha* to occasional boob paradise.

So I had mixed reactions to Rebekah Curtis' book Boob Hell. It's a memoir of breastfeeding her first baby, and it's filled with tortured descriptions of the pain and embarrassment she endured while trying to figure out how to nurse. This wasn't your ordinary sore-nipples-for-a-few-days kind of pain, it was close to 3 months of constant, excruciating pain, even when she wasn't nursing. She had a nipple so deeply cracked that it essentially split in two. She couldn't hold her daughter or bear to have anything brush against her breasts. Turns out she had a raging thrush infection and (my interpretation here) a baby who didn't latch on right. Between those two, she endured more than I think I ever could have. But Rebekah doesn't set herself up as a hero or even a warrior. She feels like she's failing no matter what she does: "I was failing at breastfeeding, and failing at quitting breastfeeding. Human history had never known a more stupendous failure."


Besides the physical pain of a bad latch, cracked and bleeding nipples, and a thrust infection, Rebekah also endures another form of hellish punishment: shame, embarrasment, and loneliness. At times, I felt impatient with the narrator. Newly postpartum, she has a houseful of family staying over. She feels trapped and overly self-conscious. So she ends up nursing her baby on a folding chair in her bedroom, completely miserable yet unwilling to either A) just nurse the baby and let others deal with it or B) ask the unwanted guests to leave. Yes, I know that it's hard to field friends and relatives when you're newly postpartum, but it's even worse to be "nice" and then suffer for it (and then complain/cry in secret).

Even after she's been nursing for a while, she still feels terribly awkward and embarrassed to breastfeed in front of anybody. Here's a scene when she's visiting her mom and grandma (referred to as "Grandma" and "Great Grandma"). 
     I positioned Baby to start on the safe boob. I had her burpie, a fresh nursing pad, and my receiving blanket. But when It came to the feature presentation, I found myself stalling, making unnecessary adjustments. I just didn't want anyone to watch me feed the baby; not my mom, not my grandma, not anybody. I grimly draped the blanket over my shoulder and Baby, reached underneath it to unhook my bra, and tried to hold her in the appropriate range, but she started flailing and gasping and soon the blanket was tangled around her head and arm, and my face was burning. Was Great Grandma still watching? I didn't want to look.
     "Come on, Baby," I muttered desperately, pulling the blanket back up. But she couldn't get it. Her hands flew and pulled off the blanket again and she cried in frustration. I wanted to do the same. "I'm sorry, we're terrible at this," I said angrily. "Well go upstairs and come back when we're done." I reassembled myself and hauled Baby upstairs where we could sequester ourselves in a bedroom.
     Dad [Rebekah's husband] knocked on the door a few minutes later and stuck his head in. "Doing OK?" he asked.
     "Why do they say you should just feed the baby wherever you are? Why don't they tell you that babies can't figure out how to eat without you being totally exposed? Why do they make you think that it's totally no problem to feed a baby under a blanket? Don't their babies kick and squirm and cry? I hate all those people, whoever they are!"
 Or this scene at a friend's house, where she and three other moms are gathered for lunch:
     We sat around Christine's table while the bigger kids ran and screamed. The lady with the newborn started nursing her, not with as much subtlety as I preferred to employ. I wasn't sure if I should look away. She didn't seem to be trying to make a point (no need in this group); apparently she just didn't care. It was distracting: although I wouldn't normally be looking at her chest, I now had to look consciously elsewhere. I struck me that this was how polite men must always feel around women in boob sweaters or short skirts.
     Baby also had lunch coming. But with Other Mom doing the deed at the table, I could hardly excuse myself to the living room. It would even feel rude to try the blanket trick, since she hadn't. My inner anchorite muttered, See, this is why you don't go out with people. I dug through my diaper bag at length as a signal that I was about to need everyone's eyes to be considerately averted. I straightened, unhooked, helped Baby latch, and hoped that my face wasn't as red as it felt. The other girls dutifully conversed around me.
     "Are you OK?" asked Christine after I started laughing at their comments again to signal my return to group interaction. "I mean, is it going OK?"
     "Yeah, it's no biggie," I said, smiling tightly.

Rebekah's character is aware of these inconsistencies. One time, she is sitting in her husband's office nursing her baby. A woman walks in, looking for Rebekah's husband. Rebekah's immediate reaction is to feel uncomfortable and embarrassed, even though the woman doesn't mind and hardly notices the nursing. Turns out the woman has been struggling with infertility. Rebekah reflects:
Why had I spent all this time angry about nursing mothers being forced out of society to feed their babies, and then when someone who doesn't have a problem with me feeding my baby shows up I get mad and scared?

Reading Boob Hell made me wonder how we ought to talk about breastfeeding. Should we teach that it's something that many or most women can accomplish with the right information and support? Or is talking about breastfeeding in a positive and encouraging way setting women up for failure? Should we instead focus on the potential problems and difficulties so we're not painting an unrealistic picture for new mothers? I understand the reasons for both approaches. Rebekah definitely feels duped by all the breastfeeding books she read. To her, breastfeeding is hard and painful, period. Anyone who says otherwise is simply not telling the truth: 
     Baby and I were in the middle of a feeding when my aunt stopped by to inspect the newest family member. "How's it going?" she asked me.
     Kind of rough," I said.
     "Rough how?"
     "Feeding."
     She nodded. "Yup, that's the way it goes."
     Maybe if we all know this, we could give each other a little warning? I thought. "Everybody at the hospital and all the books say that you might be sore for a day or two at first but after that you'll be fine as long as you're doing it right," I said.
     My aunt snorted and rolled her eyes. "Anybody who's ever done it knows that's not true," she said. "But at least you can drink again, right?"
     Can I?" I asked.
     "Oh, sure," she said, "You just can't get hammered."

On top of feeling shell-shocked at how difficult breastfeeding was, she can't even be honest about how she is actually doing:
     A friendly grandpa-type asked me how we were doing that Sunday at church. Just fine, I prevaricated.
     "You know, at this age, they pretty much just sleep and eat and cry!" he observed jauntily. "And the sleeping you don't mind, and the eating you don't mind, but that crying can sure wear you out!"
     I nodded, smiled. He patted me on the back and moved on. I stumbled into my husband's study so that I could get the crying over with before another caring person tried to be friendly. Why did I have to lie about this? Why did I have to pretend that I wasn't in the darkest valley of my life? Didn't anyone know, didn't anyone suspect that things might not be that great for a new nursing mom? Why were we all keeping up this act? I could only conclude that every acquaintance who'd talked to me since Baby's birth had no experience of breastfeeding, because if they had, their words to me would surely have been less presumptuous. The eating you don't mind. The eating you don't mind. The eating you don't mind.

Rebekah finally emerges from boob hell almost 3 months postpartum. Her constant pain between feedings finally dissipates and then, at a friend's urging, she tries gentian violet for her thrush infection. It does the trick after lots of ineffective remedies and useless advice from doctors and lactation consultants.

Boob Hell is self-published. I caught the occasional error and found her usage of titles rather than names confusing (her daughter was named "Baby," her husband was named "Dad," and her mom was named "Grandma"). The writing style is so-so, but her story is positively wrenching and at times frustrating. Frustrating that women go through so much suffering--whether undeserved, unexpected, or self-inflicted. Frustrating that she received so much bad/ineffective advice from numerous health care professionals Frustrating that she couldn't be open about her struggles with mothering and nursing.

I haven't ever been in Rebekah Curtis' shoes. And she's never been in mine. Towards the end of the book, she writes: "I don't understand the people who claim to have no problems and no pain, but I'll take their word for it since one of them was my grandma." I am hesitant to pronounce that breastfeeding WILL be hard and painful and difficult. Or that if you do everything right, you'll NEVER have problems. I know that it CAN be hard, and is for many women. But I'm still uncomfortable with spreading the idea that is is MEANT to be that way.

For those reasons, I'm not sure if I would recommend this book to someone who has never breastfed before. It's simply too overwhelming and discouraging. However, Boob Hell would be great for breastfeeding veterans--especially those who have faced and overcome challenges. Or for those postpartum moms who feel lost and isolated, whether they're cruising along in boob Omaha or stuck in the seventh circle of boob hell.

Paperback available at Lulu ($9.49) and Amazon (paperback & $2.99 Kindle). 

* Pleasant, nothing terribly remarkable, hum-drum (phrase borrowed from Rebekah Curtis)

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Tuesday, December 04, 2012

24 weeks pregnant

I'm starting a weekly photo series of my pregnancy...with a little twist.


How to make a pregnancy photo silhouette:
  • Stand in front of a large window during the day and have someone take a photo. Wear a swimsuit, tight-fitting clothing, or your birthday suit for best results. (I wore a bikini for this photo. Since Eric doesn't usually come home until dusk, I set a tripod on top of a steamer trunk at the foot of my bed. I stood in front of our bedroom window and coaxed Dio, my 3-year-old, into taking several photos.)
  • Use the pen tool in Photoshop to create a vector silhouette. It's faster to simply do image>adjustments>threshold, but the results will look sloppy.
  • Find a digital picture frame. The frame I used was originally from a real photo, so the edges aren't as smooth as a vector photo frame. Turn the frame into a new layer so you can put your silhouette "inside" (underneath).
  • Insert your silhouette.
  • Using the text tool, type any numbers or text you'd like to appear on the frame.
  • If you're going to do a series of images, save your work first as a Photoshop document so you can reuse the photo frame. Simply delete the old silhouette layer and add the new one each week or month. 
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Monday, December 03, 2012

Pregnancy: Month 2

We were in Alberta this summer during my second month of pregnancy. I made a "Waterton National Park" quilt square since we spent a lot of time there. I started feeling really exhausted in Alberta and couldn't figure out why :)


This picture was my inspiration. I still have to embroider the Prince of Wales hotel onto the hill in the foreground...

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Sunday, December 02, 2012

Pregnancy: Month 1

I've been a looking for a different way to document this pregnancy. I've done weekly belly shots, a belly cast, maternity photos, and henna belly paintings. What else could I do to create a record? I can't say this with 100% certainty yet, but this baby might be our last. I've seen some fun ideas on Pinterest, but many of them are too doctored, too elaborate, or just not me.

I love what Baby Makin' Mama's been doing, but honestly if I tried to do anything resembling a fashion shoot, I would bust out laughing. Plus I'd run out of outfits after about 3 pictures:

from http://www.babymakingmachine.com/category/pregnancy

Cool idea, but I don't have a professional photographer to follow me around:

from blog.hannamac.com

I also didn't want to copycat someone else's ideas. So this Amazing Pregnancy Journal had to be free, realistic to accomplish, and meaningful to me--even if it wasn't professionally done or repinned a thousand times on Pinterest.

I've made birth quilts for both Dio and Inga, so I thought I'd continue that tradition and make a month-by-month pregnancy quilt. Each block represents something significant or memorable from that month of pregnancy. It will have nine blocks for the pregnancy plus three for the "fourth trimester" (and to be honest, 12 worked better than 9 to fit crib-size quilt dimensions).

So here's Month One. I call it "Head in the Clouds" because I had no idea I was pregnant at first. Between a likely early miscarriage and then a super light period (that probably wasn't a period after all), it took me a while to even think of taking a pregnancy test.

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Friday, November 30, 2012

Family pictures

A year ago, I altered a bridesmaid's dress for a photographer in exchange for a family photo session. We finally got it done last month--only it clouded over and began raining mid-shoot! Despite the weather, I still love how they turned out.








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Tuesday, November 27, 2012

Support Mother Health International on Kveller

Want to support Mother Health International? It's easy--just click on www.kveller.com/vote/ and vote! The winning organization receives $5,000 from the Harold Grinspoon Foundation. You can vote once every day (and more often if you have other email addresses). Voting ends November 30th.

Mother Health International is a non-profit organization dedicated to helping pregnant women and children in areas facing natural disaster, war, or extreme poverty. It currently operates birth centers in Haiti and Uganda and is opening a third in Senegal.

Birth Center in northern Uganda
Birth Center in Jacmel, Haiti

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Saturday, November 24, 2012

Bottom first, naturally

On the heels of the 3rd International Breech Conference is this article about the resurgence of vaginal breech birth in some Australian hospitals. 


Read the rest here.
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Friday, November 23, 2012

Breech wishlist

After attending the Heads Up! Breech Conference, I came up with a wishlist of things I'd like to see happen:

1) An online, searchable database of breech catchers
This would be tricky to figure out with the illegal/alegal status of some midwives, so we'd have to figure out if we'd only include people who are "out of the closet." I'd like something that a person could search for online by country, then state/province/region, and get info on who will catch breech, where they work, and what they're like (are they hands-on or hands-off, have they done upright breeches, do they do 1st or 2nd twins, primips, etc). Kind of like the VBAC ban database.

The first thing to do is come up with a good domain name, something that's an obvious search term. 

2) A website dedicated to information on breech birth. 
There are lots of individual sites out there, but I'd like to have a good, visible website that is THE jumping off place for women seeking information on breech. We'd link to a lot of other sites, but also have our own content (abstracts and full texts of research on breech birth, ECV, and more).

First step: obtain a domain name. Any ideas for this?

3) More research on women's experiences of breech birth. 
I've actually done the research already but haven't ever written it up. Definitely a project I want to get to in the near future. I have hundreds of responses from women with both surprise & known breeches via a a short-answer and essay-response survey. I'm actively looking for co-authors--preferably with experience coding & analyzing qualitative research; please contact me if you're interested.

4) A comprehensive review of literature on breech birth since 2000. 
I was talking with Benna Waites, author of Breech Birth, at the conference (and a few others at the breakfast table, please remind me of who you were!). We discussed the real need for a good review of the literature post-TBT. Benna's book was published in 2001 and I haven't seen anything else like it since since.

1st step: collecting all of the articles.

2nd step: organizing them into a table or spreadsheet. Even having all of the citations, abstracts, and a brief 1- paragraph discussion about methods and applicability would be so helpful.

3rd step: would be to write this up into an article for publication in a medical journal.

This is also something I'd like to be a part of, but it's too much for me to tackle on my own right now. Contact me if you'd like to be part of this project. The first 2 steps could be a collaborative effort, facilitated via shared Google docs.

5) Practical instruction on upright breech birth, written primarily for providers. 
This would need to come from providers with extensive experience doing upright breech births (Betty-Anne Daviss, Dr. Louwen & Dr. Reitter, Jane Evans, etc.). I'm envisioning something with lots of practical how-to information and step-by-step illustrations--more of a textbook chapter for physicians and midwives than a consumer's guide. We need a good written resource for teaching upright breech birth, especially something written for providers working in a hospital setting. (OOH midwives have Anne Frye's textbook to turn to. I wonder what updates she might make to her chapter on breech after attending the conference?)

6) And, of course, more breech catchers!
I'd love for every woman to have access to a skilled breech catcher within a 60-90 minute radius.  I know I'm just dreaming, but wouldn't it be fantastic if at least one hospital in every larger city had a breech team?

What's on your breech wishlist?
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Wednesday, November 21, 2012

Thanksgiving activism

I know many of my readers might be visiting family and getting ready for tomorrow's Thanksgiving feast...but don't forget to join in these two campaigns!


Your Voice Counts Day

Did you have a wonderful, empowering birth experience? Did you have a traumatic birth experience that made you feel hurt and confused? Stand up and tell somebody! On Thursday, November 22nd (Thanksgiving) join us in mailing letters to hospital administrators, birth center directors, and other birth workers to tell our stories. How will hospitals and birth workers know how they're doing if we don't tell them? Whether your birth happened sixty minutes ago, sixty days ago, or sixty years ago, your experience matters. We cannot be ignored if we unite and flood these establishments with letters at the same time. Stand up and be counted on Your Voice Counts Day.

*NOTES: We realize the post office is closed on Thanksgiving. You can mail your letter on a different day if you desire to hand it to a mail carrier. This event is also open to spouses and significant others. Birth is not just our experience as women but our families experience too. Ask your partner to help or even write their own letter.
 
 
 
The Purpose: How can we fix a problem when so many don’t realize there is one? Awareness: The Big Campaign is an awareness campaign to encourage and insist that all maternal healthcare providers practice evidence-based care.

It takes an average of 20 years for proven “best practices” to become “standard” practice in hospitals and providers’ offices. For the sake of mothers and babies everywhere, we can’t wait 20 years. The long-term effects of preventable and unnecessary procedures are just starting to be realized.

Take Action: November 26th – 30th, 2012.

Register now to join us in The Big Walk-In. Once registered, you will receive a letter to hand out when you WALK into a maternity healthcare provider’s office near you. Leave it with a little note of thanks for their dedication to birthing families.
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Tuesday, November 20, 2012

Call for submissions from the Heads Up! Breech Conference

I'm wrapping up my session summaries of the Heads Up! Breech Conference. I've written the summary about the Frankfurt Study and am waiting to hear back from Betty-Anne Daviss (she is taking a look at my notes first, since their data is unpublished). I was busy preparing my own presentation on Sunday afternoon, so I missed the panel on Informed Choice. Then I had to catch my flight home as soon as I was done speaking, so I missed the last session on medicolegal issues. So here are some submissions I'm looking for:
  • Write-up of the panel on Informed Choice (Jean-Gilles Tchabo, Kimberly Van Der Beek, Jane Evans, Martin Gimovsky, Anke Reitter)
  • Write-up of the Sunday afternoon panel on Medicolegal Issues and Ethics in Breech Birth
  • Write-up of the Monday Into the Breech skills workshop with Jane Evans, Andrew Bisits, Anke Reitter, and Betty-Anne Daviss
  • Write-up of any of the breakout sessions I did not attend
  • Write-up of my conference presentation Connecting the Dots: The Future of Birth Advocacy 

If you'd like to submit something, please email me!
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Monday, November 19, 2012

Alternative Modalities For Turning the Breech Baby: Heads Up! Breech Conference

Day 3 

Alternative Modalities for turning the breech baby

Marie Julia Guittier: Hypnosis for pain control during ECV
Marie Julia, a midwife & PhD candidate from Switzerland, led a study looking at hypnosis for controlling pain associated with ECV. From an earlier study, they found most women would recommend ECV, but many found the pain to be severe (27%) or excruciating (4%). She and her research partners wanted to know if hypnosis can reduce pain during ECV. They compared 122 standard care women with 63 having hypnosis during the ECV. They didn’t observe any statistically significant differences in women’s perceptions of pain. Success rates did not improve with the hypnosis group. Physicians had mixed evaluations of hypnosis; most (72%) thought hypnosis facilitated the ECV, although some did not.

Lindsey Vick: Hypnosis to turn breech babies
Lindsey Vick is a hypnotherapist and Reiki practitioner from Virginia. She referred to a study by L.E. Mehl examining using hypnosis to turn breech babies. There were 100 women in the hypnosis group and 100 women in the control group, matched for obstetrical & sociodemographic characteristics. Women in the study were between 37-40 weeks gestation. 81% of breech babies in the hypnosis group turned, vs 48% of comparison group. She started collecting data on women whose breech babies she was encouraging to turn using hypnosis. For more information, see Mehl LE. Hypnosis and conversion of the breech to the vertex presentation. Arch Fam Med. 3.10 (Oct 1994): 881-7.

JoseLo Gutierrez: Moxibustion
JoseLo is an acupuncturist in the DC area. He spoke about moxibustion for turning a breech baby. It can be used on all toes, but the little toe is the most effective. It can also be combined with massage, essential oils, and hypnosis.

Nancy Salgueiro: Chiropractic to prevent & turn breech presentations
Nancy is a prenatal and pediatric chiropractor in Ontario and is Webster’s certified. She briefly explained the main approach & goals of chiropractic care: to ensure that the brain is communicating effectively with the body via the nervous system. She then discussed the bio-mechanical connections (ligaments) between the uterus and the pelvis. If there are misalignments in the pelvis, the ligaments will pull on the uterus and not give the baby as much space to grow, develop, and maneuver. Webster’s Technique is a chiropractic technique that can be used for anyone. For pregnant women, it’s often used for helping a breech baby turn by adjusting the sacrum and by relaxing the round ligaments in the front of the uterus. It involves no direct manipulation on the baby.

She referred to a retrospective study in the Journal of Manipulative and Physiological Therapeutics that found Webster's technique effective in helping breech presentations turn. (I think that this study has a lot of methodological flaws; I'd like to see a better designed prospective study with matched control groups. On the other hand, chiropractic care is unlikely to cause harm, so the only real downfalls of trying Webster's during pregnancy is the cost.)

Nancy recommends starting Webster’s as early as 34 weeks to have time to get the pelvis balanced. Don’t put it off till the last minute. You can also do this before an ECV to keep the baby from flipping back to breech after it’s turned.

Adrienne Caldwell, Massage Therapy
Adrienne is a bodyworker and massage therapist certified to work with pregnant and postpartum women. After her first baby was breech, she started focusing on helping women with malpositioned babies. She agrees with Nancy to start early and ensure you have a balanced, dynamic body.

My thoughts on this session: 
Women with breech babies are highly motivated--often desperate--to encourage their babies to turn. I've heard numerous stories of women who tried everything to turn their breech baby: inversions, handstands or flips in a pool, ice packs on the abdomen, music played near the pubic bone, knee-chest positioning, chiropractic, hypnosis, moxibustion, ECV, and more. The evidence for some of these modalities is weak. On the other hand, these techniques are unlikely to cause harm. I'd love to see vaginal breech birth a real option for all women, but in the meantime I'd also like to see more quality research on what really works to turn breech babies. With vaginal breech birth being out of reach of most North American women, turning the breech baby is often the last chance to have a vaginal birth.
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Sunday, November 18, 2012

Taking notes at the Heads Up! Breech Conference

Ruth Mace-Tessler captured this picture of me typing 100 miles an hour at the breech conference. It was so nice to have have any little kids to take care of during those three days. There's no way I would have been able to take such detailed notes with Inga in tow.

I'm thinking of compiling all my conference notes into a downloadable PDF. It would be nice to have a printed booklet to give to interested care providers or pregnant women. Would this interest you? Anyone with some awesome graphic design skills who could fancy it up for me?


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Is breech pathological or normal? Heads Up! Breech Conference

Day 3 

Debate: Is breech presentation pathological or a variation of normal?

Marek Glezerman and Betty-Anne Daviss
Moderated by Ken Johnson

After two intense days of learning and discussion, we were all ready to let our hair down a bit. Dr. Marek Glezerman and Betty-Anne Daviss engaged in a debate that was both earnest and hilarious. Ken Johnson (Betty-Anne's husband) heckled his wife for wearing "attire unbecoming a midwife" (she was dressed in asymmetrical layers of purple and green, evoking a tree sprite) and for unfairly influencing the audience when she signaled Dr. Andrew Bisits to stand up and begin playing his violin. But behind the silliness was an earnest question: is breech pathology or simply a variation of normal? What are the implications for how we understand and categorize breech?

Marek Glezerman opened the debate, arguing that the answer to this question has consequences. Why should he enter this mine field of a questions? If you want to struggle for the right cause, you should address the existing concerns by refuting them or handling them.

Personal experience isn’t a very scientific place to start, but it’s still important. He started his residency 39 years ago and has since headed three OB/GYN departments. Over those years, he’s been the chair for around 200,000 deliveries. The chairman’s position is important because all adverse outcomes eventually land on his desk.

He next discussed several studies on breech presentations:  

Schutte et al, 1985 compared malformations between breech and vertex presentations. They found  more malformations at each gestational week with a breech presentation than with a vertex. Schutte observed: "It may be that breech presentation may not be coincidental but rather a product of the quality of the infant…if there is some truth in this supposition, it is unlikely that medical intervention … can improve the outcome." (Schutte MF, van Hemel OJS, van de Berg C, van de Pol A. Perinatal mortality in breech presentations as compared with vertex presentations in singleton pregnancies: an analysis based upon 58,189 computer-registered pregnancies in The Netherlands. Eur. J. Obstet. Gynecol. Reprod. Biol. 19 (1985): 391–400.)

Breech delivery is associated with more anomalies and higher mortality rates, irrespective of delivery mode. Remember that association is not necessarily causation. About 20% of breech presentations can be explained by these anomalies; the rest are unexplained. Breech presentation is an independent risk factor for neurological pathology and cerebral palsy, irrespective of mode of delivery.

Ochschorn et al, 2009: found that length and coil numbers in the umbilical cord were different in breech vs. vertex presentations. The cords were shorter (57 v 64) and had fewer coils (5 vs 12). We don’t know the significance of this phenomenon, just that it exists. (Ochshorn Y et al. Coiling characteristics of umbilical cords in breech vs. vertex presentation. J Perinat Med. 37.5 (2009):525-8.)

Another interesting study by Sekulić et al found decreased expression of fetal movements in the first few days of life in breech presenting babies (all born via CS) which cannot be explained by anything else. We don’t know the important or reasons behind this phenomenon. He’d love to see more long-term studies of breech babies vs. cephalic babies in all aspects. (Sekulić S. et al. Decreased expression of the righting reflex and locomotor movements in breech-presenting newborns in the first days of life. Early Hum Dev. 85.4 (Apr 2009):263-6.)

Haruta et al compared breech and vertex babies born by elective cesarean. The breech presenting babies had lower umbilical arterial oxygen levels, more hypoxemia, and lower 1 minute Apgars. (Haruta M et al. Umbilical blood-gas status at cesarean section for breech presentation: a comparison with vertex presentation. [Article in Japanese] Nihon Sanka Fujinka Gakkai Zasshi. 41.10 (Oct 1989): 1530-6)

Kean et al found that breech babies at term had more state transitions in utero than vertex babies. They concluded that “breech babies are different.” (Kean LH et al. A comparison of fetal behaviour in breech and cephalic presentations at term. Br J Obstet Gynaecol. 106.11 (Nov 1999): 1209-13.)

Conclusion:
We know that breech babies are different. What is the key to that lock? Is it a cesarean? Glezerman argued no--there’s no connection between mode of delivery and these differences. So is breech a variation of normalcy? No. Is it pathology or associated with pathology? Sometimes yes, but not all of the time. But we can say that “Breech babies are different.”

Breech presentation is not a variation of normalcy; that’s using the wrong tool for the right goal. Breech presentation may be the result, not the etiology, of pathology. Patients need to be informed, and courts need to be informed. A persistent breech presentation may need special attention. But cesarean section is no panacea.

We need more long-term prospective data on babies born breech and on persistent breech presentations. We also need to distinguish between statistical and clinical significance. There are many statistical significances in breech presentations that have no clinical significance.

Betty-Anne Daviss asked: Whom does pathologizing the breech serve best? Whom does it harm?

from Gloria Lemay
To answer that question, she outlined the "3 Ps of corporate global society": Privatize, Professionalize, and Pathologize. (This was a play on words on the 3 P's of birth: Passenger, Power, and Pelvis.)

1. Privatize: World Trade & World Bank
Our world is seeing increased privatization of education and health care. Health care has become a big business, and interventions are sold as commodities. She discussed the 2012 WHO report by Lauer et al on what drives demand for cesarean section. Are cesarean rates rising because of women's choices? They found that the demand-side model is much smaller than previously reported. the supply-side model has some modest effects on cesarean rates; the more it’s available, the more it will be used.  But they found that health system factors have the largest impact on cesarean utilization rates. These factors are institutional and related to the legal environment in which health-care decisions are made. They concluded that the debate about patient choice vs. doctors' preferences isn’t the right question; “health system factors may be an important overlooked population-level determinant.” They suggest that cesarean rates might be most amendable to change through modifying health-care policy. (Lauer JA et al. Determinants of caesarean section rates in developed countries: supply, demand and opportunities for control. World Health Report (2010) Background Paper, 29). 

2. Professionalize:
The 3 original modern professions were the clergy, lawyers, and doctors. Now everyone’s trying to professionalize--midwives, doulas, childbirth educators, lactation consultants, and more. She discussed Inuit responses to professionalizing their birth attendants: “licenses are for fishing; why would you want to professionalize midwives?”

3. Pathologize
Pathologizing what used to be normal life events is endemic in our society and particularly affects women.

Next, Betty-Anne discussed three legal cases involving breech births, illustrating how a pathological model of breech adversely effects both parents and birth attendants, regardless of whether there is a bad outcome. I don't have sufficient information about these cases to discuss them here, but I will list the key details and suggest further research if you're interested:
  • Alison Osborne vs. the State of California, 1999
  • ____ (midwife) vs. Washington State: Sorry, I don't have any more details on the case name or date. It happened at a time when many women were having unassisted births for their breech babies because they could not find any hospitals willing to do breech births. A midwife attended a breech birth and transported for a prolonged 2nd stage; there was no bad outcome. She was put on trial, and the verdict was, interestingly, that "the midwife needs to learn how to do footling breeches before she continues to do home birth breeches. 
  • Ruth Abigail Light, 2010, Illinois: baby removed from parent's custody because the parents had a breech birth at home. 


Conclusion:
Breech presentation carries a higher risk than vertex presentation, but we shouldn’t necessarily pathologize it. We should instead approach breech from an informed choice perspective. We need to look at absolute and relative risk. Rather than pathologize the breech, we need to pathologize cesarean sections. We also need to address the undocumented severe mental health disorders stemming from traumatic births and lack of choices.

Marek’s response: He’s convinced that 70-80% of women don’t need a hospital to have their babies safely, while 20% of them do. Our problem is we don’t know in advance who will need hospital care. We’ve constructed our whole maternity care system for those 20%. When he started his residency, perinatal mortality and morbidity were much higher than they are today. Let’s not just blame medicine, since it has done a great service in bringing down mortality and morbidity rates.

Our problem is not black and white. Breech is not absolute pathology or absolute normality; it’s in the gray zone. Residents need much more skill and experience to learn vaginal breech birth than to learn how to do a cesarean section.We need to re-skill our physicians.
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Friday, November 16, 2012

The PREMODA Study: Heads Up! Breech Conference

#breech
Day 2
Dr. Sophie Alexander: 
The PREMODA study

Dr. Sophie Alexander participated in the Belgian arm of the PREMODA study, which is often referred to as the "antidote to the Term Breech Trial." In France and Belgium, there’s always been a strong tradition of vaginal breech birth (VBB) and a strong belief in the value of vaginal birth. Thus VBB is still formally taught in residency programs.

After the TBT and other studies came out, PREMODA (an observational prospective study) was designed. They used the same criteria and outcome measures as the TBT, except the decision for a cesarean section (CS) or VBB was the woman’s, not randomized. It was a huge study with over 8,000 women registered. If a hospital participated, then all term breech presentations in the entire hospital were included in the study. Thus there were no recruitment issues as with the TBT.

The PREMODA study investigated 3 groups: planned CS, planned VBB, and unplanned CS during a planned VBB. Data collection took place over 1 year from June 1 2001- May 31 2002. In total there were 8,105 women in the study. 28% of planned VBB ended in a cesarean during labor. They had much less crossover in the planned CS arm (< 1%) than in the TBT (10%).

Their results were significantly different from the TBT's results. In the PREMODA study, none of the antepartum deaths were related to choosing a vaginal breech birth. Almost all neonatal deaths were due to lethal conditions or severe congenital malformations. There were two deaths associated with unbooked (unplanned) home births, one of which was a concealed pregnancy. 

The PREMODA study found somewhat higher levels of immediate morbidity (low Apgars, need for ventilation) after a VBB compared to a planned CS, which is not surprising. The differences were small and transient. Vaginally born breech babies had somewhat more birth trauma, but levels were not very significant.

Overall, if you compare the TBT with the PREMODA study, rates of death or serious neonatal morbidity were much lower in the PREMODA study. Remember that the criteria and outcome measures were identical in both studies, making it easy to draw comparisons between the two.

Since the original PREMODA study, they’ve written up two more articles based on the data they collected:

Based on this study, the RCOG came up with new breech guidelines in 2009. Dr. Alexander commented, "We think the antidote is working." 

After Dr. Alexander's presentation, there was an interesting discussion:

Q: How many deliveries constitutes an experienced attendant? 
A: At her hospital, they require at least 5 year’s residency to be considered experienced in breech. They have 5-6 breeches/month, and residents work 1 day in 4. So on average, a resident could see up to 75-90 planned VBBs over a 5-year period. They allow for the individual's feeling of confidence and interest in doing VBB.

Anke Reitter: In Frankfurt, they train as many people as they can, but then they leave and go onto other units and stop doing VBBs. It’s really just her and Frank Louwen doing all the vaginal breech births.

Sophie Alexander: Her unit has at least 7 people who are comfortable with VBB.

Betty-Anne Daviss: The Canadian guidelines are now turning to require a certain amount of VBBs on hands and knees, since that’s what women are asking for. Some of the older OBs who have done lots of breech births aren’t skilled enough in this new technique.

Marek Glezerman: How do we define who is skilled in VBB? The TBT study defined it as “someone who considered themselves skilled and was approved by the department chair.” He finds this very problematic. He strongly believes that we need standardization in breech skills. We need a model that’s the same everywhere--we can do this via simulation training. Residents should undergo a structured theoretical and practical training program with drills.

He was a pilot years ago, and he learned again and again how to do emergency landings. Even today, whenever he is on an airplane he instinctively searches out good locations for an emergency landing. The same goes for OBs. All OBs should have thorough breech training on a model so they have the skills if needed (even if they don’t choose to attend planned VBB).

Don’t forget the importance of peer pressure among OBs—if you can get some obstetricians who are confident in VBB, it might pressure the others into obtaining those skills so they don’t look bad in front of their peers.
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Thursday, November 15, 2012

Selection of Candidates for Vaginal Breech Birth: Heads Up! Breech Conference

Day 2
Selection of Candidates:
Factors to Consider 

Panelists
  • Andrew Bisits (Australia)
  • Martin Gimovsky (USA)
  • Jane Evans (UK)
  • Sophie Alexander (Belgium)
  • Marek Glezerman (Israel)

The panelists answered the question: What are your criteria for a vaginal breech birth?

Andrew Bisits prefers a woman who is informed, along with her partner, and is motivated. He looks for a good level of understanding and cooperation. He always feels better about the situation if there's continuity of midwfiery care.
  • EFW <4000g 
  • Baby not growth-restricted
  • Presentation of baby prior to labor doesn’t bother him. He looks at presentation at the onset of labor; he will advise CS for footling at onset (but he doesn’t always do a CS in this situation).
  • Labor progress: once the woman is in established labor, she should progress roughly ½ cm per hour. You’re not necessarily watching the clock; these are just overall guidelines.
  • Pushing stage: if the baby is not descending after an hour, he will start asking himself questions. After 2 hours, he will definitely advise a CS.
  • Does not exclude primips.

He uses ultrasound to assess the baby’s weight. He doesn’t do pelvimetry. He used to, but he found it distracted him from the criteria of labor progress. He uses continuous monitoring during labor. If a woman strongly does not want cEFM, they will come to a compromise agreement.

Dr. Martin Gimovsky agreed with everything Bisits said. In additon, he can never stress enough the importance of support people (labor nurses, doulas) besides midwives and physicians. The key to VBAC or VBB is to go for the low-hanging fruit. He’d much prefer a mutlip frank breech than, say, a primip footling breech that weighs 4000g.

He was trained to measure the pelvis for all babies. He uses cEFM and CT pelvimetry. With a breech baby, a prolonged active phase of labor is a sign for concern. Dilation: the cervix dilates as the muslce fibers are taken into the uterus, not depending on the presenting part. Thus he feels epidurals are acceptable if the patient uses them. They do cord gases after the birth. The pediatricians are always unhappy with him and others who do VBB. An ideal candidate: frank breech, 37-42 weeks, EFW under 4 kg, woman comes in in active labor. Primips or multips are okay. He is more concerned than others about pelvic capacity and feels a CT scan is advisable.

Primary principle: first do no harm
Second prinicple: patient autonomy

Midwife Jane Evans noted that her parameters as a midwife are wider since they take on women who have no option of VBB in a hospital. Her first prenatal visit is 2-3 hours long. She ensures women have all the information on all of their options. She only has access to one hospital in her area, so mostly vaginal breech birth is done at home. Many of the women want to start labor spontaneously. She doesn't have a criteria for the baby’s presentation. If a footling comes down too early, have the mum lie on her left side and tickle the foot gently. The baby will tuck it it back up inside. As long as we have progress throughout the labor and 2nd stage (and don’t forget the placentas!) and baby and mom are okay, we await and facilitate the birth.

Q: What size of babies are you catching breech?
Her breech babies range from 2750-5000g. The average weight is probably 3000-3500 g. If a nice fat, well-grown bum doesn’t go through, the head won’t go through. IUGR is a contraindication; she uses her hands to determine this. She “palpatimates” the size of the baby. She feels she’s more accurate than a scan in determining IUGR.

Dr. Sophie Alexander of Belgium remarked that she works in an entirely different context from Jane Evans. In her country, if a woman has a breech baby, the guidelines say you have to offer or dicuss the option of a VBB. Most of their criteria have evolved from tradition as taught by older OBs. She follows her College guidelines strictly. These include:
  • Routine scan at 32 weeks to determine presentation
  • 32-37 weeks if breech
    • talk with mother/parents
    • discuss options if baby remains breech and ECV fails. Give her access to full information (i.e., TBT and PREMODA)
    • tell her she can use positional or moxa interventions but there is not good evidence
    • reinforce motivation for physiotherapy (kinesitherapie) unless she is really sure she prefers and elective cesarean section
  • Attempt ECV at 37 weeks, unless woman has objection or contraindications
  • If ECV fails,
    • CT or MRI pelvimetry
    • Ultrasound for EFW
    • Prenatal visit to explain the process of breech, emphasize the need for teamwork

Criteria for vaginal breech birth at term:
  • Adequate pelvimetry 
  • EFW 2500-3800g
  • Not footling
  • Flexed head in labor
  • In Belgium, there are mixed practices on allowing primips, nuchal cords, and full (complete) breeches
  • A previous cesarean will have a repeat cesarean if labor doesn't begin by 42 weeks

Admission guidelines:
  • Confirm frank or complete (full) breech
  • Confirm head flexion
  • Be sure labor is well-established before admission

In labor:
  • If the woman departs from the partogram, allow only twice two hours to get back into a normal labor pattern. Can augment with oxytocin for 2 hours. If still no progress, try ARM and wait 2 more hours. If still no progress, suggest cesarean section. 
  • Epidural is a general rule for all women attempting VBB
  • At 9 cms, inform the OB, pediatrician, anesthetist, & midwife
  • At full dilation:
    • allow passive 2nd stage for up to 60 minutes
    • then put up oxytocin drip and start pushing
    • pushing should bring some descent within 20 minutes and birth within 60 minutes, otherwise move to cesarean
    • birth should be expedited if there are anomalous FHR or breathing attempts

Dr. Alexander acknowledged that these guidelines are quite strict. However, vaginal breech birth is politically delicate and one bad outcome could mean the end of VBB. They have to be careful to stick to the rules--as much as she has some personal frustrations with them

Dr. Marek Glezerman commented that we all want mostly universally acceptable criteria. In Israel, he has no choice but to adhere to the guidelines (which he helped write!).

Choosing the right vaginal breech patient means you’re already there—you already have the skills, the motivated patient, and the safety net. Unforutnately we’re not all in this ideal situation yet.

He posed some interesting questions:
  • What about emergency breech delivery, where there’s no time for choice or discussion? What if you have no access to skills on premises?
  • What about comparative risk assessment?
  • How do we convince OBs, the public, or the courts that VBB is a viable option? Don't ignore the reality of the medico-legal environment. We need to convince courts that risk assessment means looking at all aspects of the situation, not just at the risks of vaginal breech birth. 
  • And most importantly: Why are there so few OBs in this room? The conference organizers said there were 10 OBs in attendance, not counting the speakers. But there should be hundreds at this conference!

Dr. Glezerman also contrasted the ideal world vs the real world. If you cannot avoid complications or disaster, you better be prepared. There will always be situations where you need to deliver breeches vaginally. Unfortunately, we have buried or lost our skills. Three generations of residents have never had the chance to learn VBB, so we cannot offer choices. Everyone is on their own.

Ethical limits of autonomy:
Autonomy means both the right to choose and the right to refuse treatment. But it’s not the same as the right to demand treatment. (I wish he had further expanded on this point. Is a vaginal breech birth "demanding treatment"? Or is the inevitable consequence of refusing a cesarean--since it will occur on its own? These questions apply equally well to VBAC, since refusing an elective repeat cesarean will inevitably end in a vaginal birth after cesarean, making it less of a "treatment" and more the physiological result of pregnancy.)


How do we convince those who are opposed to offering vaginal breech birth?
We need to use the right tools. We can’t use only moral reasoning. OBs have been trained to listen to data. We have to focus on the risks involved with cesarean sections. CS is not just another delivery mode; maternal mortality for elective CS is 3x higher than for vaginal birth. There are incidental and consequential morbidity from cesarean surgeries. What price does the public pay for higher rates of CS? Cesareans have an impact on future reproduction, higher maternal mortality and morbidity, longer hospital stays, higher stillbirth rates, placental abruption, placenta previa, and more. Placental pathology is “The Great Risk Factor” with cesarean section. 50% of all emergency hysterectomies are done for placenta previa or placenta accreta. The risks increase exponentially with each additional CS.

Overall, cesarean section carries more risk for the mother than a vaginal birth. If so, is it better for the baby?  No. Cesarean section is associated with higher fetal/newborn morbidity, respiratory problems, bonding/feeding problems, prematurity, etc. There is unequivocal data showing increased risk to the baby from cesarean section. 

Arguments for reviving vaginal breech birth:
  • Because CS is more risky for mother
  • In well-chosen women there is no advantage for the baby compared to CS
  • There is not always a safe alternative
  • Women's right to choose
  • For when CS isn’t an option
  • For the second twin
  • To reduce unnecessary CS
  • To prevent subsequent CS
  • During a cesarean surgery: you still need to be skilled in breech delivery techniques to be able to delivery a breech baby or a deeply lodged vertex baby safely! 

He referenced several studies:

Read more ...

Breech Birth at Home: Heads Up! Breech Conference

Day 2
Breech Birth At Home:
Considerations, Safety, and Informed Choice

Panelists

  • Mary Cooper
  • Diane Goslin
  • Stuart Fischbein
  • Jane Evans
  • Moderator: Ina May Gaskin

Mary Cooper mostly works with 5 Plain communities: 3 Amish and 2 Mennonite. She also serves “English” moms. It’s very important to share with clients what a breech birth means. They also need to read up more about it on their own. She demonstrates breech births to her clients with a doll & pelvis. Because of her client population, most of her moms think breech is simply a variation of normal. There’s also less fear associated with breech among her clients. She has a few supportive doctors who will do VBB if the mom is a multip.

She tells her moms that the labor will be different than a head-down baby and that she will sit on her hands and not do anything until the very end. She might ask them to take a different birthing position if something is not going well, otherwise they choose the positions they prefer.

She has a very good relationship with a local physician and hospital, so when she transports, they have everything ready for her. You have to listen to your moms. There might be residual fears left over from previous births, so don’t be surprised by emotional ups and downs during labors. Carefully observe the mother and baby and use your own skills.

She’s done 59 breeches and transported 3 of those.

Diane Goslin has helped over 6,000 babies come into the world. She works in Lancaster, PA. She serves both Plain (50-60%) and English communities. She has always offered VBB because her community also considers breech a variation of normal. Hospital birth is largely not an option for most of her clients due to finances and lack of health insurance. Many also plan very large families, so CS is not an option. She has become more comfortable watching the process unfold and has become more hands-off over the years.

She has a higher anomaly rate among her Plain communities (because they do not seek prenatal ultrasounds generally) and a resultant higher rate of breech babies. During prenatal visits, she explains the mechanics of breech and goes through the birth process with a doll & pelvis. Over 30 years, she’s transported two vaginal breeches, both at the mother’s choice. One was for an elective cesarean, the other for a transverse second twin.

If we start a breech, we finish it unless complications arise. They’ve had a good number of incomplete & footling breeches. They get many primip breech referrals. They follow the mother as she moves and chooses different positions.

Most of her moms consider breech a variation of normal; they’ve watched animals give birth and are comfortable with the mammalian birth process. The key advantage of birthing at home to her mothers is they’re not bringing fear into the birth environment. They supporting and encouraging their mothers. She occasionally dismisses students who bring too much fear into the room.

We need to be able to recognize when intervention is necessary and what to do. It’s good to work with other midwives to share knowledge and experience. She asks midwives to come along with their referral clients.

When she started attending births in the late 1970s, she went to a birth solo and the woman's baby was presenting breech. She applied what she’d learned about ECV and turned the baby. She put on the husband’s back support belt in place to keep the baby positioned. That was her first breech experience. She’s done many external versions at home with careful monitoring & listening.

Because most of her clientele considered home the natural place to give birth, they had to facilitate a lot of their desires for VBB. And because so many of them would have large families, she didn’t want to “wreck their career” by starting off with a cesarean. They also had the time to progress at their own rate. They found many primips would take a long time to come down. As long as the mom had energy and baby was doing well, they saw no reason to hurry the process.

Her clientele’s babies start out at 3500-4000g or above; she has a Germanic population with large pelvises and large babies and they’ve had good outcomes all around, breech or head-down.

The inherent risks of breech are inexperience and fear. Her job as a mentor and preceptor is to give other midwives as much exposure & experience as possible in an environment free of fear. Would most of her clientele choose a hospital birth if it offered VBB? Not the Plain population, but many of her English referrals coming in from out of town would definitely go for vaginal breech birth in a supportive, relaxed hospital environment.

Stuart Fischbein is a referral source for practitioners in the LA area; most of his breech clients he doesn’t meet until late in pregnancy. His initial visit is 1 ½ hours; subsequent prenatal visits are 1 hour. He works under more of a time crunch with his breech referrals. At a time when there should be peace & calm in a woman's pregnancy, there’s lots of turmoil. He reviews their history and if they fit the criteria, he reassures them that there’s a good chance of success. Breech labors progress or fail for the same reasons that head-down labors progress or fail.

He gives his clients evidence-based articles to read, discusses the TBT, and explains why most area doctors do not support VBB. Of his 7 criteria, the most important one is having the “right mental stuff”
  • EFW 2500-4000g
  • Flexed head
  • Frank or complete
  • no major fetal anomalies (uterine anomalies are not a contraindication, although he keeps an eye out for increased risk of retained placenta)
  • wait for labor to begin
  • baby has to tolerate labor
  • woman has the right mental stuff

Why is he doing home births? He never would have thought that he’d be doing this. When he finished residency at Cedars Sinai in 1986, it was the busiest hospital in country with 22,000 births/year. They saw everything: breeches, forceps, class IV heart disease, etc. He came out of there with really good training. After he was done, midwives approached him to be a backup physician, and he agreed. For 10 years, he backed midwives and then started a collaborative practice with CNMs in Ventura County. After about 15 years there, the environment became very hostile. Both the pediatricians and anesthesiologists gave his practice a hard time because his patients didn’t want Vit K, bottle feeding, mother-baby separation, early cord clamping, etc. Eventually the midwives were banned from attending births at the hospital for a year. Then the hospital forbid him from doing VBACs and breeches. He could have hired a lawyer and tried to fight the administrative process, which is a losing proposition and costs a fortune. At the same time, he was asked by midwives if he’d be interested in doing home births. He thought for about a “nanosecond” and then said yes. He was fortunate to have that option, and he’s never looked back. He doesn’t miss the craziness and micromanagement of the hospital environment.

There is a place for home birth. He hopes that physicians will consider this as an option down the road. His eventual goal is to build a regional center for breech deliveries. But for now he can offer people a choice in a home setting, although finances can be a challenge.

He’s very quick to tell people if they’re not a good candidate. He’s not trying to be a hero; safety is the utmost issue.

Jane Evans worked with the NHS for 20 years before becoming an independent midwife (IM). The NHS became more and more restrictive and compromised the care she was able to offer women. IMs are still scrutinized and judged for their profession.

She spends a lot of time talking through the options, the risks, and the parameters of safety. It all comes down to informed decision-making. The woman has to make the decision for that baby, that pregnancy, for her family and for herself.
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Breech Birth in American Hospitals: Heads Up! Breech Conference

Day 2: 
Breech Birth in American Hospitals: 
Challenges and Solutions

Panelists:

Dr. Dennis Hartung works in a small community hospital in Hudson, Wisconsin close to the Twin Cities. He has good support from his hospital and does about 14-15 vaginal breech births per year. He often works with Gail Tully (a.k.a. the Spinning Babies lady) and enjoys doing hands & knees breech births. He accepts women seeking VBB or VBAMC at any point in their pregnancy. Women have come from as far as Chicago, an 8-hour drive, to have him attend their breech birth. Pediatricians tend to be more reluctant to VBB because the babies more frequently come out needing help. None of his 3 OB partners or his CNMs feel comfortable doing VBB, so he doesn’t have any backup.


Dr. Martin Gimovsky works in NYC. He argued that Samuel Shem's book The House of God offers some of the best advice for breech birth: keep the collective pulse down. After reviewing the changes in obstetrics between the two World Wars, Dr. Gimovsky commented that maintaining flexion is key in all mammal births. The breech positions we’ve been discussing today (referring, I think, to upright breech birth) are physiologic. He also defended the appropriate use of technology. Natural processes sometimes are catastrophic. The other extreme is that we don’t need meddlesome interference. We need moderation in how we practice.

Obstetrics in the US has always been defined by pediatrics. Doctors like Edmund Piper developed tools to prevent the high perinatal loss common at that time. After WWII, CS became safer. In the 60s and 70s, NICUs came into existence, allowing smaller babies to survive. When he began practicing, patients and doctors trusted each other. This isn’t the case today.

He noted how it’s important to have the skills to deliver breeches even when doing cesarean sections. At his hospital, they use full-size simulators to teach emergency breech simulations. He also noted the increased risks of multiple cesareans. But unfortunately, many of his faculty don’t have training in VBB.

Dr. Fischbein: Is there any chance of VBB being taught well enough so that it could actually come back as a choice in American hospitals?

Dr. Gimovsky: It's very geographic; patient expectation and hospital rules vary by area. He likes the idea of a breech delivery team, like they do with their accreta team. Why has that not taken on in the East Coast? Because of the overwhelming fear that providers have.


Dr. Michael Hall noted that in Colorado, especially in Boulder, women want choices. He’s been doing VBB forever. He hopes that a lot of doctors will be pushed back into doing them due to community pressure. If the attitude in this room today could be spread over the country, we’d be seeing a lot of changes come more quickly. His hospital has been good to him.

We’re starting to see the complications of multiple cesareans more often, with the increase of accreta, for example. He just met with some ACOG people last week who spoke of the need to bring back these lost vaginal delivery skills. He’s confident that breech is coming back (like VBAC has started to). The hospital or his malpractice insurance has not bothered him. He now has begun teaching VBB at the University of Colorado Hospital. The perinatologists are getting excited about VBB. Someone needs to be confident and competent to do it and to teach it. The younger residents want to do it; it’s the OBs in their middle years who don’t know how and who don’t want to offer that choice.

Dr. Fischbein: How do we balance, as OBs, our fiduciary interests (putting patients’ interests above our own) and the beneficence-based model of care (having an ethical obligation to support reasonable, evidence-based choices, even if you don’t agree with them)? Do you or your colleagues agree with this line of reasoning?

Dr. Hartung: We don’t want to coerce our patients into things they don’t want. He accepts patients at any point in their gestation who want a breech birth. Once the doulas in his community know something, the word spreads like wildfire. He tries to be respectful of a woman’s decision after giving her the information and choices she has. There are people who ignore the information about the reasonable safety of VBB. It’s coercion to not allow them these choices. Pediatricians in particular don’t seem to understand the concepts of autonomy and a woman’s choice, but he thinks it’s the right path.

Dr. Gimovsky: The ethics start at the principle of “first do no harm.” OBs should refer to other providers if they are unwilling to provide vaginal breech birth. The internet is helpful for spreading information quickly. “The issues about autonomy and safety concern everyone, regardless of where we come from.” Consumers need to demand VBB; providers will not do it on their own.

Dr. Hartung: The US healthcare systems’ incentives are backwards; providers and especially hospitals make more money from cesareans than from vaginal births.

Dr. Fischbein: Insurance companies could decrease the CS rate overnight if they simply paid twice as much for a vaginal birth as for a CS. Vaginal breech birth requires more time, skill, and experience,  so it should be reimbursed at a higher rate.

Susan Roque (an OB from North Carolina) noted that in her area, Medicaid now pays slightly more for a vaginal birth than for a CS. She attends vaginal breech births at her local hospital and recently founded a freestanding birth center, Natural Beginnings, with two CNMs.

Michael Hall said the same thing is true in his area with Medicaid reimbursement. Midwives now get reimbursed at the same rate as obstetricians. We have to go after the attitudes of the doctors.

Dr. Fischbein: We really need breech centers in the US where women can come from all around, so you can get enough volume to teach future generations.
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