Saturday, July 02, 2016

Dr. Frank Louwen: The Re-Invention of Vaginal Breech Birth

First Amsterdam Breech Conference, Day 1
Dr. Frank Louwen
The Re-Invention of Vaginal Breech Birth

Dr. Scheele introduced Dr. Frank Louwen by noting that Frank's lessons on all-fours breech birth changed his hospital's policies. He and his colleagues were in a “magic trance” after Frank visited their hospital.

If Dr. Louwen's work interests you, you might want to read my summary of Frank Louwen's and Anke Reitter's presentations at the 2nd International Breech Conference in Ottawa, Canada in 2009.

Now on to Dr. Louwen's presentation:

Dr. Louwen began by arguing that safety and maternal wishes are not in conflict with vaginal breech birth. Done properly, vaginal breech birth can reduce complications for mother and babies. Cesarean sections have complications for mothers, for future pregnancies, and for babies. The important questions are: “Is breech pathology or a variation of normal? What is normal in breech? What is pathology? Can we exclude higher risk breeches from vaginal birth? Can we include births that would go well vaginally? What is the influence of maternal position on outcomes?”

He noted that we don’t have a choice to debate about vaginal breech birth because women are coming in pushing with breeches. If you only have cesarean section as an option for surprise breeches, you will injure the mother and baby. We have to make vaginal breech birth safe. When a mother presents with a breech emerging, you need the skills to do a safe vaginal breech birth—not a cesarean!

Dr. Louwen mentioned that he loves cesareans—if he has a good indication for them. But they also have risks, including unexpected pediatric ones (see, for example, studies by Thavagnanam, Cardwell, and Almgren cited below). Do we have an indication for cesarean with breech babies? To answer this question, he noted that to do an intervention, you need an indication. And indications are related to pathology, not to normalcy.

He noted that Germans are really good at following the latest evidence in obstetric practice. So when the Hannah Term Breech Trial (TBT) came out, showing equivalent outcomes for the mother and benefits to the baby for planned cesarean, they believed the trial. But they didn’t look closely enough at the numbers. This led him to wonder if they should trust in those numbers, since the TBT outcomes were outrageous even among the planned cesarean group.

He noted that Glezerman’s response to the TBT explained what was wrong with the analysis of the TBT data. He also noted the changing recommendations for breech delivery in the 2000, 2001, and 2015 Cochrane systematic reviews. He also cited obstetric guidelines from around the world, all advising an experienced attendant for a safe vaginal breech birth. But around the world, people are losing this experience.

Dr. Louwen argued that we do a lot of unproven procedures in obstetrics. He wants to convince us that breech is normal, not pathological. We can prove this hypothesis: if something happens spontaneously and if an issue resolves itself without any help at all, then it is normal. If it needs help, it is pathology.

Why is Amsterdam the right place to talk about the breech from the German perspective? More than 80 years ago, a famous German obstetrician came to an international conference in Amsterdam about breech—Erich Bracht. From Bracht's experience in Berlin, he noticed that the less you touch the breech, the fewer the complications. That was revolutionary at the time. Until he gave that presentation in Amsterdam, every breech was extracted because of the influence of François Mauriceau. Bracht advocated the opposite: it was a revolution. The only maneuver is to move the baby around the symphisus of the mother as the torso and head are being born. See this illustration:

He next told the story of how he came to (re)discover upright breech birth. He was on a telephone call with Bracht’s book open to the above illustration. During the phone call, he walked to the opposite side of the desk. He glanced at the book during the phone call and saw this:

He didn’t recognize the pictures. He stopped the call immediately and looked again more closely. An idea came to mind: “What would happen if I turned the woman around?” It took several months to actually do a breech birth on hands & knees because he and his colleague Dr. Anke Reitter had to re-learn everything “upside down.”

His first upright breech birth was a primip. He told her about his new idea of having the woman upright, but he'd never actually done it before. She said, “Try it out. If it’s not working, then turn me around!” In the event that it worked, she insisted on having him show off her photos to audiences like ours!

What is normal? What is pathology? 
Frank Louwen noted the disparity between well-defined cesarean techniques and poorly defined vaginal breech births--one reason why studies comparing the two are subject to criticism. With cesareans, the techniques are described, codified, and clear. But with vaginal breech birth, we have many unanswered questions: could the woman walk? Take a bath? Did she have drugs? Oxytocin? Episiotomy? What position was mother in? Everything is well-described in the planned cesarean group, while you know almost nothing about planned vaginal group. That’s the big problem of Hannah trial: what exactly are we comparing in those two groups? What is the influence of the maternal position?

This led him to another question: Is upright positioning the intervention? Or is having a mother on her back the intervention?

He noted that women in his unit go onto the hands & knees position just when the buttocks of the child begin emerging. Before that, the women are free to walk around and do as they please. He never does episiotomies during a vaginal breech birth because the evidence points to rising complication rates.

An old saying goes: “If you deliver a breech baby, never look at the face of the child.” This was true for women birthing on their backs. However, if the women are turned around on her knees, the saying now goes: “If you deliver a breech baby, always look at the face of the child.”

Cord compression and CTG
With supine breech birth, once the shoulders are born, you have to hurry deliver the baby because the weight of the baby is compressing the cord. But with upright births, the baby doesn’t compress its cord—it decompresses its cord! When woman is upright, the only time you have a pathological CTG is with true pathology.

Posterior presentations
A posterior baby during a vaginal breech birth would be considered pathological and in need of assistance. When the woman is on her back, you have to turn the baby 180 degrees with your hands On hands & knees, the situation might resolve itself spontaneously. (He showed us a film clip of this happening.)

Normal vs. pathological
Frank reiterated that vaginal breech is normal. If you don’t need any intervention, it’s normal. If you need an intervention, it’s pathology. More than 90% of all breech deliveries are normal and spontaneous if the baby is normal sized, frank breech, and anterior. Normal sized = not too small. Big babies are not a concern. Putting a woman on her back even in cephalic births is pathology because it requires an intervention (releasing the shoulders once the head is born).

“Never pull, only push the baby.”

Pathological situations in breech births:
1. Weak contractions during pushing.
2. Dorsal posterior (if they don’t turn themselves in labor).
3. Footling presentation. When the woman is on her back, you often see pathological CTGs during the birth. In the upright position, you sit, watch, and encourage the mother to push during contractions, not in between. If you want to check CTGs, do it directly on the baby’s chest, not on the mother’s belly!!!

Women in his unit are not required to have epidurals; it depends solely on the mother’s wishes. 2/3 have them and 1/3 don’t. He noted that women need activity in labor, so a walking epidural is a must. If your unit can’t do true walking epidurals, he advises against them.

Rixa's note: We saw several films of women on his unit with walking epidurals. The women seemed to have a full range of movement and were able to squat, stand, and walk on their own.

Q&A session

Q: Midwifery students in the Netherlands are taught breech as an emergency skill, since they have to refer known breeches to their OB colleagues. So the midwives only have training in breech on the back with Lovset & Bracht maneuvers and an episiotomy. I'm trying to convince my midwifery colleagues to teach breech on all fours. But they say because it’s an urgent situation and they are not experienced, we should not teach them that. What is your opinion on that? What should we teach midwives who might not do a lot of breech births?
A: How many vaginal breech births do you need to attend until you’re experienced? We are living in another age with the availability of video clips. You can see thousands of breech births by watching video clips again and again. In the first 200 or so vaginal breech births I attended, I had high levels of adrenaline. Now I can just sit back and watch, relaxed. I often don't remember my first-hand breech experiences because I am so in-the-moment. Video clips, on the other hand, can give us experience. Ask women to allow you to film their births. Since I started, I have always said that the video belongs to the woman and she may share if she wishes to give her permission. You get really experienced by watching vaginal breech birth on videos. I encourage you to use the techniques of the 21st century, not of the 19th century. Use videos again and again. Pause it. Examine it closely. Then you can attend ten or so births in a unit and I would consider you ready to go.

Q: What is your opinion about speed of delivery of the head in an upright position?
A: If the baby is fine, you can wait. If there’s a pathological situation (prolonged 2nd stage, etc), you can help the head by doing a shoulder press. But if it’s normal, you just wait.

Q: What about quick decompression of the head?
A: No relation to any pathology. Not a complication. Just let the head come out, slow or fast.

Q: In a midwifery school, you still too often learn with women on their backs. We need to be very conscious of our history and of how paternalistic our system has been towards women. We must remember to see childbirth from a human perspective. As professionals, we shouldn’t focus on taking over and controlling the woman. It’s crazy how we as providers start turning the world around. We need to support women in choosing the position they want to be in.
A: We have to be the expert to recognize immediately when there is any pathology. We don’t have to influence the normalcy. We have to realize how can we detect pathology as early as possible and which intervention would be the best to correct it. If we realize that we don’t have to view breech in general as a pathology, then we are ready to really discover what is pathology and what is not in a vaginal breech birth. The Hannah trial was just comparing two pathological situations.

Q: How many patients are you hoping for in your own trial?
A: I'm not looking to detect mortality rates, but to compare the necessity of maneuvers. The Frankfurt data has been submitted for publication. In it, we found a significant reduction in maneuvers using hands & knees vs on-the-back positions. Interventions lead to more complications. So if you have fewer interventions, you have fewer complications. Our study had about 350 in both groups. I'd like to conduct an international multi-center study comparing the same things.

Q: You said something about a "normal sized baby" meaning a baby that is not too small. What is not too small?
A: A baby that is big doesn’t result in higher complications for the baby (such as low Apgars, NICU, etc). But unplanned in-labor cesareans (also called secondary cesareans) are higher with big babies. In my data, the bigger the baby or the smaller the pelvis, the higher the cesarean rate is at the end. But bigger babies aren’t related to higher neonatal mortality. On the other hand, smaller babies are related to higher complication rates, so they can be an indication for CS. My cutoff is somewhere around 2,000 - 2,500 grams. It’s a tricky number to pin down exactly.

Sources cited:


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