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.
Read more ...

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.
. 
Read more ...

Wednesday, November 14, 2012

The Impact of Choice: Heads Up! Breech Conference

Day 2:
Panel on The Impact of Choice

Panelists:
  • Celine Ouellette (Ontario)
  • Ruth Mace-Tessler (England)
  • Cathy Harris (DC & Georgia)
  • Kimberly Van Der Beek (Los Angeles)
  • Benna Waites (England)
  • Moderator: Robin Lim
From left to right: Benna, Kimberly, Cathy, Ruth, Celine & Robin. Photo from the Coalition for Breech Birth Facebook page

Celine Ouellette is from Deep River, Ontario, 2 hours north of Ottawa. She works in the child protection system. She is the mother of one daughter. When she was 34 weeks pregnant, her midwives discovered her daughter to be breech. By 36 weeks, she went in for a consult. Her midwives told her to prepare to have a cesarean. The midwives she had didn’t feel they had enough experience with breech. She was devastated and decided to advocate for a breech birth. A midwife in Ottawa was recommended to her; she spent hours talking about safety, risks, and mechanisms of breech. She tried 2 ECVs, did Moxi, chrio, inversions—nothing worked. By the second ECV, she accepted that her daughter wouldn’t turn. She enjoyed the rest of her pregnancy.

At 40 weeks and a few days, Celine woke up and felt a small leak. She called her midwife in the morning. She went to see the midwife in Ottawa; she was given antibiotics for GBS+ and sent back home to her community midwives. She also consulted with an OB who was supposed to be breech-friendly. During their meeting, he told her about a bad outcome in detail. Neither her husband or her midwife were there. She went about her day. Labor had started the next morning, so about 24 hours since SROM (later on in labor, her water broke again, so the first one was either a small leak that resealed or a rupture of one of the amniotic layers). She labored at home until 4 cm and went into the hospital around lunchtime.

The nurses didn’t want her to eat, but she was hungry so she did. Around 1:30 pm, the on-call OB (one she hadn’t spoken to) recommended Pit in a few hours and then a c=section. She said, “I’m just getting started and we’re not talking about that right now.” The Ottawa midwife was there but couldn’t attend to her because of hospital policy. Celine refused the offered Pitocin. Around 4:40 pm, the OB recommended Pit again, and she agreed to it. She did 2 hours of Pit. A few hours later, she did N2O2. She’s progressing slowly. She felt she needed to be on hands & knees and couldn’t have an epidural. She kept watching the clock, waiting for the breech-friendly OB to come in. He finally comes in and checks her around 9:30 pm. He wasn’t comfortable with how things were going and recommended a cesarean because of membrane rupture, EFW was near the upper limits, and GBS+. Her husband was devastated and unable to provide support at that point. She couldn’t see any way to do things differently.

Celine asked for a few minutes to think, and she talked with her midwife. She reluctantly consented to the cesarean. The midwife checked her again and said “I can feel a change; I’ll be right back!” Celine tried one last time to argue for the possibility of a vaginal birth, but the OB said she was likely to end up with a traumatic delivery and forceps. She knew she couldn’t do that to her baby. Even though the midwife had discovered some change in her labor progress, at this point she felt trapped and went through the CS anyway. Her midwife stayed by her side the whole time.

Her daughter wasn’t over 4000g. She had the cord around her neck twice, which might not have been a big deal anyway. She feels she would have been fine if she’d been given a fair shot. Care providers need to know that almost 2 1/2 years out, she still can’t get through her birth story without crying. It will continue to affect her throughout any future pregnancies. It wasn’t just her birth. It was her experience of becoming a mother.

Ruth Mace-Tessler lives about 2 hours outside of London. She had one baby born in 2009. She commented, "It’s not so much the actual birth, but the whole picture leading up to that point, that dismays us." She found out her son was breech around 28 weeks. Time passed, and he was still breech. She felt excited: “I like a challenge; I can do this!”

Her sister was very helpful, recommended a doula, and gave her Jane Evans’ book on breech. She saw nine different midwives prenatally, so she had no continuity of care. She had to explain over and over the same thing. She had an U/S at 37 weeks at the hospital. She were booked under a consultant who wasn’t breech friendly, and she never saw him, just one of his junior doctors. He asked her, “So, ECV or section?” She said, “no thanks.” He then presented her with a big list of risks of breech birth. They went home feeling more bemused than anything else.

At 41 weeks, Ruth saw a new midwife who expressed support for her plans. She hit 42 weeks. She was starting to get pressure to have an induction, but she waited and labor began spontaneously. She wanted to stay home for as long as possible, where she felt safe. Nobody else felt comfortable, though. She kept getting unsolicited phone calls from various midwives who weren’t comfortable with her plans. They kept telling her all the things that could go wrong—while she was in labor! Every time she’d get a phone call, her labor would stop. Her husband lost it and started crying. At that point, she got a knock on the door; it was another midwife she didn’t know who had turned up because she was her team leader. The midwife came into her bedroom. Ruth told her, “At this point, I’m feeling harassed!”

They eventually went into the hospital. The minute Ruth got there, there was a senior midwife who was very experienced with breeches. This midwife was quite wonderful and supportive. At that point, Ruth had been laboring a long time and she was really tired. Contractions started to peter out, and the midwife said, “I think we need to think about other options.” Ruth broke down and cried. Her baby's bottom was already beginning to show. They did move to surgery, and it was so for Ruth hard to deal with the contractions knowing that they weren’t going to lead to a vaginal birth. She still feels really sad; maybe if she’d gone in earlier on and spent more labor time with the supportive midwife...maybe she’d have had a vaginal birth.

Cathy Harris is the mother of two children and lives in the D.C. area. Her first baby was born in a birth center in Virginia. That was her perception of normal; she knew how wonderful and beautiful birth could be. Her breech birth with her second baby took place when she was living in Georgia. Unfortunately, there were few options for breech there. Her breech son is now 13 months old. For this second baby, she planned on a natural birth in a hospital, since there were no birth centers in her area of Georgia. She really wanted a water birth the second time; "If I can stay underwater for as long as possible," she thought, "people can’t bug me." She’a also a childbirth educator, and she started teaching for an OB's office. She really liked the group of midwives & OBs in that practice.

At 39+4 weeks, she discovered her son was breech. In the back of her mind, she had known something was different and had been saying so the last few weeks of prenatal visits. She finally insisted on an ultrasound, and the baby was indeed breech—and a footling. She immediately tried to do everything she could to get her baby to turn. She convinced her OB to give her another week. She met with another doctor and a home birth midwife. A day before her scheduled c-section, she met with her OB and asked for more options, for the possibility of a VBB. They said absolutely not; you have to have the c-section.

The day before, waiting for her c-section the next day, was probably the worst day of her life. She knew what giving birth could be like. She knew inside of her that she had the strength to birth her baby. Her husband didn’t even understand it—knowing she was going to have to go in and relinquish all control to people she didn’t know. In contrast, her first birth felt like it was hers. Right before the surgery, a new nurse came in and said, “Do you have a birth plan with you? I want to know your original plan was so I know how to help you and so you can be empowered to breastfeed your baby.” This gave her a lot of peace during the surgery. She also made it very clear to the people in the room that the surgery was not what she had chosen. After her c-section, she took to breastfeeding the way she’d taken to her first birth; it was what she had control over. That was where she found her empowerment. It was one of the best and one of the most horrible days of her life.

Kimberly Van Der Beek (wife of actor James Van Der Beek) shared her two birth stories recently on a People blog. For her first baby, she’d been talked out of her dream of having a home birth and ended up with a more medicalized experience in a hospital. With her second baby, she found her son was breech at 37 weeks. She was very naive and didn’t even assume that meant a c-section. However, her doctor said it was absolutely not possible to have a VBB. She tried everything to turn the baby. Her chiropractor recommended 2 options: one OB who does routine epidurals, inductions and forceps for breeches. Or Dr. Fischbein, who does them at home. She was thrilled to hear that. She listened to everyone’s fears, tried to be a reasonable person, and asked questions. She realized there were risks with every choice. You need to know that you’re assessing risks vs risks, not risk vs no risk.

A few days after she’d switched providers, Kimberly received an email from her original OB expressing her worries and fears. She wrote to Kimberly: “Your child, I’m afraid, is going to have problems with fetal stress. God forbid, he could die, and I’m very concerned. I think you need to schedule a cesarean for Saturday.” This was one of the most natural-friendly doctors in LA writing this letter. Despite these obstacles, her husband was always a tremendous support.

The following Monday at 3 pm, her water broke. Dr. Fischbein confirmed rupture of membranes, checked that everyone was fine, and told her to call him when labor began. She took a bath, spent some special time with her daughter, and went to bed. At 5 am, she woke up with a really strong contraction. They were 3 minutes apart, strong, and long within half an hour. Her doula and midwife arrived—she was 9 cms. (Dr. F was with another laboring breech mom 65 miles away!) Her body began pushing, but she tried her best to wait for him to come. When he arrived, he was very casual and relaxed. He let her go into the zone and do her thing. Kimberly told the audience--specifically the maternity care providers-- "In the future, let us go into our zone." She also noted how being in a comfortable environment helped her find the strength she needed: “When you’re in your own bed, with the sun rising, you can go there. You can make it happen.“ Her son was born at 7:42 am. She concluded by asking, "How can I help this process along? If I can do anything to help, let me and my husband know."

Benna Waites, author of the 2001 book Breech Birth, (I reviewed this book back in 2008) had a breech baby born in 1998. At 36 weeks, the conversations started. He’d been breech for a while, but everyone said “he’ll turn, he’ll turn.” She’d read enough to know that the evidence supported VBB as an option. This was pre-TBT. She’d also seen pictures of an upright breech birth and felt that made sense. Her partrner had passed out while watching a c/s video, so they were both very keen to avoid surgery if they could. The consultant they saw said that cesarean is best for the baby. She disagreed and said her reading of the evidence indicated otherwise. He said, “Okay, but we’ll do it in lithotomy and use forceps.” It sounded "medieval" to her. It wasn’t something she could do.

She went through mourning for the loss of her lovely, peaceful pregnancy. She also mourned for her colleagues. She’s a psychologist and evidence-based medicine was a big thing in her field. There was something shocking about obstetricians lying to her. “I was angry, not just scientifically disappointed.”

Benna lived on the edge of London and began phoning hospitals and midwives. She also spoke with some independent midwives. Finally, she contacted an OB at King’s College Hospital, Donald Gibb, who was known to be progressive. He was really up for doing an upright vaginal breech birth. She described him as "committed and quite keen." But he had lots of international conferences. He said, “I can’t guarantee that any other consultant will give you a TOL on all-fours, so I’ll come in for your birth as long as I’m in the country.” Incredibly enough, she went into labor when he was in the country.

Like many of the other panelists, Benna commented that "It was the struggle that was so important. The birth itself was the most normal, natural, straightforward part of the process." This hospital wasn’t the most beautiful place in the world. Her attending midwife (present while Dr. Gibb was on the way) was quite frightened. Dr. Gibb and her partner gave her fantastic support and confidence. Labor went smoothly. Her son was born spontaneously on all-fours in front of a vast audience; she wanted others to observe so they could share that knowledge. This experience set up her journey into motherhood with a cause for celebration, not mourning.

This also spurred her to write the book Breech Birth. It was a 2-year project, finished in 2001. It reviewed all the evidence available about breech birth at the time. Her main message for OBs who only look at the TBT is that “your ignorance and your fear cannot be the reason for our lack of choice. That is not okay.”
Read more ...

Core Skills for Attending Breech Births: Heads Up! Breech Conference

Day 2:
Core Skills for Attending Breech Births

Panelists:
  • Dr. Michael Hall
  • Ina May Gaskin
  • Jane Evans
  • Betty-Anne Daviss
  • Gail Tully (moderator)

Michael Hall:


He’s been getting a little more support for what he’s doing recently, although many doctors are glad he’s doing it and not them! He’s got into “trouble” for not only breech, but delayed cord clamping. He’s done breeches for 30 years; he never quit doing them, so they all started funneling to him when everyone else stopped doing them. He gets super motivated women coming to him for breech from all over the Rockies; interestingly, most of his own patients really just want the C-section.

1st core skill: Hands Off
Leave your hands off and don’t try to pull the baby out. We have this natural instinct to want to help the baby. But we’re there to help the mother birth the baby, not to deliver the baby. I’ve seen more damage done by pulling than I’ve ever seen by maternal pushing. It’s the same for shoulder dystocia; let the mother do the work and get that baby out.

2nd core skill: Encourage Maternal Pushing
Sometimes you have to encourage the mother to push once the baby is halfway out (unless the cord is beating really well). He gets much better results encouraging mothers to push than having them  gently breathe the baby out; this is where your clinical skills of watching and knowing the mother's and baby’s signs are important. Each mother is individual and every situation is different.

3rd core skill: Freeing Nuchal Arms
If the baby does not rotate to anterior as the body is emerging, you already know there’s probably going to be some difficulties. You need to know how to reduce the arms. When the mother is on her back, you have to do this much more often than when she’s on H&K. He’s become converted to the all-fours position in the last 3 years since he learned about it at the last breech conference.

4th core skill: Stay Calm
You have to have a calm touch with the breech. Don’t panic, don’t pull side-to-side, don’t flail. You need to keep the baby in line. Don’t stretch the baby’s head laterally one way or the other. Let the mother do the work. You can apply some pressure inside the perineum to make a bit more room. You can also help open up the pelvis with having the mother rock her back if she's on H&K, or doing by McRoberts if she's on her back. You want a breech birth to be smooth. It’s an art to get the right touch.

5th core skill: Freeing a Stuck Head
Remember not to pull! Pipers forceps don’t pull the baby out; they open the vagina so the baby’s head can emerge. He does “finger forceps: with the mother on her back: put 2 fingers in deeply until you hit the leveators, then pull deeply and down. This opens more room in the pelvis. That’s worked really well for him so he can avoid an episiotomy. He has only used Pipers forceps 4 times in the last 30 years.

Ina May Gaskin:


She had a difficult case with trapped arms a year ago. She did rotations similar to those in Dr. Louwen's illustration (see session on breech research) to the baby to help free the arms.

Her breech skills have evolved since Spiritual Midwifery; they do a lot more upright and all-fours births now. 

Think on your feet
If you have an Amish woman in a long dress with really relaxed abdominal muscles, the typical techniques might not work!

Handle the breech carefully
Move as carefully as you can with a breech, especially when there’s a baby with stuck arms or a stuck head.

Help the woman believe she can get that baby out
If you can do this, she can do amazing things.

Act calm
Your heart will be pounding like bad, and you have to act like you’re at a delicious picnic, as if you have all the time in the world. Somehow, you have to project a cool, calm demeanor. She tends to ask favors of the mother, rather than bark out demands. Take deep breaths. Nurses, first responders, midwives—they all need to do this.

Keep in mind Sphincter Law
If you have women with excessively shy sphincters—if, for example, they can’t pee at work or when anyone else is around—keep this in mind and make a note in your charts.

Footling Breeches
She doesn’t like for the cord to fall down with footlings, so she doesn’t mind if women lie down to slow things a bit. It’s a lot harder to tell dilation with a footling. She had one Sacrum Posterior footling that emerged nicely to the buttocks, then rotated to SA after rumping. She didn’t want the baby to remain SP and would have done something to turn it had it not rotated on its own (and most will).

Freeing a deflexed head
Have the baby hang off the end of the delivery table to flex the head (woman on her back). Suprapubic pressure using a fist; this is done by an assistant.

Jane Evans


In this room, we have mixed experiences. We first need to really understand what’s normal before we can understand and identify abnormal situations. She wants to cover the core skills for assisting at a breech and for giving the woman the confidence to birth her baby.

#1: Be aware of how the baby ought to be coming down
Don’t panic if it’s not doing everything according to the textbook; just use watchful waiting. If the baby doesn’t continue to come down and needs some help, you need to know what to do. When do we know  to step in? If the baby doesn’t do the rotation to SA as the bottom emerges, you know that something is stopping it—nuchal arms, etc.

#2: Patience

#3: Careful Observation
Look carefully at the woman’s condition. Observe the red line, the Rhombus of Michaelus, a sacrum moving upward and out of the way.

#4. Keep everything absolutely calm
This includes the woman; allow her to relax and encourage her to feel safe.

#5: Nuchal arms & trapped heads
As the baby is coming down, if you see a vertical crease in the middle of the chest, you know that both arms are forward. A crease = good. Keep your hands off the woman as well as off the breech so you don’t interrupt what’s happening.

If you see a perineum that’s very empty after the arms are out, you know the head is extended. You’ve probably already raised flags in your mind before this point. If she’s on all-fours and has an extended head, do Frank’s nudge on the clavicles to bring the chin to the chest (Jane does a modified version of this where she places her thumbs on the subclavicular space and her other fingers wrapped around the back of the baby’s shoulders. When you press, this scrunches the shoulders forward.) Then do MSV if needed.

#6: Carefully observe color of baby, tone of baby, & what the cord is doing.

#7: Work things out with a doll and pelvis so you’re intimately familiar with the mechanisms of breech. 

Betty-Anne Daviss:


Betty-Anne began with a few notes from practices at the Frankfurt unit. They do some inductions with Prepidil; Dr. Louwen never uses oxytocin unless woman is already at 8 centimeters. They do a lot of fundal pressure in Germany; their feeling is that pushing from above is better than pulling from below. Betty-Anne has done it occasionally in selected breech cases—for example, to keep a scrotum that’s coming in and out from becoming more bruised. But you want to see at least the bottom, if not more of the baby, before doing fundal pressure.

Stuck arms
When you have a a baby out to umbilicus and doesn’t rotate to SA, the arm is often caught up on the pelvis. Maybe the baby has come down too quickly. (Normal, optimum position to see at rumping is RSA; when you see LSA, it’s more problematic). You help the baby do a 180 degree turn clockwise (unless of course the baby won’t rotate that way). After you’ve helped rotate the body 180 clockwise and then 90 back, reach a finger in and gently turn the chin to bring the head back in line.

Frank’s nudge:
In Frankfurt, they think it’s better to push on the shoulders than on the clavicles to avoid fractures. This helps bend the sternocleidomastoid muscle.

Anke Reitter came up to clarify Frank’s nudge & Louwen's maneuver:
With Frank’s nudge, you never pull the shoulders down, but guide the baby backwards toward the pubic bone. Don’t fear using Frank’s nudge. The pressure is continuous, not pulsed. You might have to apply pressure for more than a few seconds. The delivery of the head is not a continuous movement. You’ll feel no movement during the nudge, then suddenly you’ll feel a bobbing movement as you continue to press.

It does matter which direction you turn the baby; it matters where the arm is. If the arm is in front of the head, you simply release the arm and sweep it out. If the arm is behind the head, you’ll need to turn the baby, but do it in the right direction. If you’re not successful after turning in one direction, you can try the other direction.

Jane Evans commented that she has shrugged the shoulders physically forward (quite gently, with no downward traction). This releases the muscles across the back and also relases the throacic spine.

Gail Tully added a few more skills:
Be skilled with resuscitation.
Keep the cord intact.
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Tuesday, November 13, 2012

Breech Research: Heads Up! Breech Conference

Day 1:
Panel on Breech Research: 
Looking Back and Looking Forward

Dr. Andrew Bisits

Andrew Bisits presented data from term breech presentations at John Hunter Newcastle Hospital collected between October 1999 - December 2010. He also suggested some future directions for research and training, including good rigorous prospective data collection, ultrasound study of births, use of high quality simulation models, and qualitative research into women's experiences of breech.

Last, Dr. Bisits commented that the physicians during this time period (1999-2010) had to be very cautious because of the delicate political situation surrounding breech birth. They were under quite a bit of pressure to react at the slightest sign during a breech labor.  He was surprised by how happy women were to have had a chance and a choice, even if they ended up with a CS after attempting a VBB. 

Dr. Anke Reitter


Dr. Anke Reitter began by briefly reviewing the implications of the TBT in Germany. She wasn’t very shocked by the findings of the TBT, based on how it was designed. There has never been a strong breech advocacy community in Germany; she doesn’t think anything like the Coalition for Breech Birth would be possible there. She also mentioned Marek Glezerman’s 2006 critique of the TBT, Five Years to the Term Breech Trial, which she felt was extremely important in changing the course of breech birth. In Germany, the rate of VBB fell after the Hannah Trial. Multips had a small but decent chance at VBB before the TBT, while primips rarely did, even before 2000.

She told Dr. Frank Louwen’s moment of inspiration when he looked at illustrations of vaginal breech births upside-down. He realized that if we turn a woman over, we won’t have to do as many maneuvers and that the breech can deliver itself. Dr. Reitter called for new terms for this new spontaneous kind of birth on H&K.

Next, she presented the results of a research study on maternal positioning and pelvic dimensions (publication forthcoming). She briefly referred to another study using MRI for breech presentations (Van Loon et al. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term. Lancet 1997; 350: 1799-1804.) This study concluded that using MRI did not significantly reduce the overall cesarean rate, but it did lead to a lower emergency cesarean rate during labor.

She finished her presentation by showing illustrations of two new maneuvers for helping assist upright breech births and mentioning the Frankfurt study of upright breech positioning, which she and Betty-Anne discussed in more detail the following day.

Marek Glezerman

He still keeps talking about the TBT 12 years later because so many of his colleagues still cite that article and don’t acknowledge any of the newer studies. He spent most of his presentation outlining the strengths and weaknesses of the TBT. I highly recommend reading his 2006 article Five Years To the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial (full text PDF here).

The TBT was a perfect fit for the medico-legal climate in obsetetrics at the time. It was fast-tracked for publication in only three weeks. Almost overnight, the entire Western world stopped doing vaginal breech births. In contrast, the 2-year followup study (White et al) took 2 years to be published. This study found that planned CS is not associated with reduction of risk of death of neurodevelopmental delay in children 2 years of age, “but more parents in the PCB groups than the PVB group reported that their children had had medical problems in the past several months.” Even though this analysis found no difference in long-term outcomes, it was too late. Except for a few isolated hospitals and providers, vaginal breech birth had gone extinct.

Dr. Glezerman's 2006 critique of the TBT attracted a lot of heat. But it also was highly influential in softening ACOG, RCOG, SOGC, and Cochrane guidelines on vaginal breech birth.

Ohter articles Dr. Glezerman referenced:
Marek ended his presentation with a call for reviving vaginal breech skills. These skills are essential not just for women who actively seek VBB or who present late in labor with an undiagnosed breech. Physicians also need them during cesarean sections.

He discussed a fascinating study on difficult vertex cesarean sections when the baby's head is deeply lodged in the pelvis. Obstetricians typically use the "push/pull" maneuver (push the baby's head up out of the pelvis, and then pull the baby out of the incision head-first) to deliver the baby. However, this method is associated with 10x greater maternal trauma than a with a "reverse breech extraction"--where the obstetrician delivers the vertex baby bum-first from the fundus.

Here's more information on the study. Email me if you'd like the full text.

Citation: Chopra S et al. Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: Conventional method versus reverse breech extraction. Acta Obstetricia et Gynecologica Scandinavica. 88.10 (Oct 2009): 1163–1166.

Abstract: Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as ‘cephalic’ with or without assistance to push up the fetal head from the vagina (head first or push method) and ‘reverse breech extraction’ (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at ≥7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during ‘cephalic’ delivery as compared to ‘reverse breech extraction’ (22.8% versus 2.2%; p = 0.001). Use of ‘reverse breech extraction’ is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.
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