Anke Reitter: New Insights from Pelvimetric MRI Studies and Maneuvers for Upright Breech Birth

First Amsterdam Breech Conference, Day 2

Anke Reitter

New Insights from Pelvimetric MRI Studies

Dr. Anke Reitter is a Fetal Maternal Medicine Specialist at Krankenhaus Sachsenhausen, Frankfurt. She specializes in breech, multiple pregnancies, high-risk pregnancies, ultrasound--and is also an IBCLC!

Anke began with an analogy: if you are in love with a soccer team, you follow them enthusiastically. It’s the same with being a breech activist. Her study will seek to put the data into practice and look at the mechanisms and physiology of breech birth.

She began by addressing the data on term breeches from the university hospital where she had worked with Dr. Frank Louwen. (See the recent publication Does breech delivery in an upright position improve outcomes and avoid cesareans? IJOG 2016; manuscript accepted.) Women came from all over Germany to this clinic to have their breech babies. Now she’s in a new clinic, building up a breech service in a hospital that didn’t previously offer vaginal breech. She noted that most women coming to Frank’s unit for breech births were primips (about 70%).

Anke noted that the RCOG's 2006 guidelines suggested lithotomy position for breech, but the new April 2016 guidelines now endorse all-fours (currently in process, to be released soon). This gives us a safety backup by having this information in the RCOG guidelines. We can change things. The new guidelines also have a summary for safe breech births.

Pelvimetry & Primip Breech

Anke next presented her unit’s safeguards and selection criteria, in particular the role of pelvimetry for primips. She feels that doing MRIs for primips gives them an extra safety cushion. The PREMODA study also recommended “normal pelvimetry.” She referenced a study by Van Loon et al (RCT of MRI pelvimetry in breech presentation at term, Lancet Dec 1997). One group’s MRI data were shown to the physicians, and the other group’s data were hidden. Many factors were the same, but the emergency cesarean rate was lower in the group where physicians knew the pelvimetry data.

Anke wants to compare the Frankfurt MRI data to the Van Loon data—does anyone know how to do this? In the Van Loon study, all women were allowed to labor, whereas her unit excluded some women due to their pelvimetry results.

Anke presented preliminary results from another study she's authoring on primips* with breech presentations. They measured the obstetric conjugates of this group of 371 women. They excluded women with an obstetric conjugate of less than 12 cms (19%). Of the remaining primips who planned a vaginal birth, over 53% had successful vaginal breech births. Annke noted that if you use pelvimetry, you have to accept that you’ll deny some women a chance at a VBB who might have been able to do it successfully. I don't have any more information on this study, except that the manuscript has been submitted.

(*If I understood Anke correctly, this means functional primips, i.e., no previous vaginal births. This could include women with previous cesarean sections).

MRI study on maternal position & pelvic diameters

Next, Anke presented results from her MRI study Does pregnancy and/or shifting positions create more room in a woman's pelvis? (J Ob Gyn, Jun 17 2014). The study examined how pregnancy or changing positions changed the pelvic dimensions. They scanned 50 pregnant women and 50 non-pregnant women (mostly midwives from their unit). Each woman was scanned in both a “modified squat" and in a dorsal spine position.

Anke's research team measured the pelvic inlet, the midpelvis, and pelvic outlet (a total of 6 measurements). The results were really exciting: modified squatting makes the pelvic inlet slightly smaller, while the midpelvis and outlet are larger. As midwife Anne Frye says, when the baby isn’t engaged yet, don’t get the woman squatting. Anke commented, "You midwives already knew that, but as a doctor I didn’t know that!"

The same thing happened in the non-pregnant group, and all of the results were statistically significant. Anke was surprised because she’d thought that the obstetric conjugate would widen with a squat, but it narrowed while the other measurements opened.

She also looked at the transverse diameter using several different measurements and noticed striking results: Big changes are happening in the transverse diameters, even more than in the first 6 sets of measurements. They observed the same results in the pregnant and non-pregnant groups. They were very surprised and very happy to see that.

Anke concluded that this MRI study doesn’t mean you have to scan every woman, but it helps explain the advantage of upright positions for both cephalic and breech babies.

Giving credit where it's due, Anke noted that upright birth positions have been used for a long time, especially with midwives.

Anke also mentioned Andrew Bisits’ work in Australia. He recently published his data in Lessons to be learnt in managing the breech presentation at term: an 11-year single-centre retrospective study (AustNZJ Obstet Gynaecol 54.4 Aug 2014.) Although most of the breech births occurred in an upright position on the BirthRite birth stool, his article only spent one sentence describing the mothers' positions. His unit's vaginal breech delivery rate was 58%.

How do we put all this into practice? 

Anke noted that we have (re)discovered new maneuvers for freeing nuchal arms and assisting the delivery of the head. With upright breech, we need fewer maneuvers compared to supine breech births (see Louwen et al 2016).

As a side note, Anke highly recommended the MODEL-med obstetric mannequin for simulation training (pictured below). Andrew Bisits has been helping the company improve the doll so the arms articulate correctly.

Know the signs of normal & abnormal with the all-fours position 
Normal: the baby's trunk faces forward
Abnormal: the baby's trunk faces sideways

Signs of normal & abnormal rotation with a supine breech:

Anke discussed this 1958 Australian textbook illustration: with a nuchal arm, the body is usually not in a front-facing position—it’s usually transverse. So the arm is drawn correctly, but not the body.

In this 1986 German textbook, she found a good illustration and instructions with the drawings done correctly. You'll see that the body of the baby remains transverse rather than A/P. This illustration shows the proper direction of rotation to try first (the baby's arm points the way).

Direct maneuvers for hands-and-knees:
1. Recognize sign of dystocia (trunk not rotated to the front)
2. To free a nuchal arm: Louwen Maneuver. Rotate 180, then 90 the other direction. Baby's hand points the way for the first rotation. Baby should end facing the mother's anus.
3. To flex the head, do one of the following:

1. Shoulder press or "Frank's nudge": press on the baby's shoulders backwards towards the mother's pubic bone (not downward). Rixa's note: I have seen two variations of the shoulder press, a.k.a. "Frank's nudge," demonstrated at this conference. Anke Reitter prefers holding the baby by its shoulders, the thumb in front and the fingers wrapped around the back of the shoulders. Others place 2 fingers (index & middle) on each shoulder and press backwards gently.

2. Subclavicularly Activated Flexion and Emergence (SAFE): Gently press the sub-clavicular space to elicit a flexion response in the baby. Gail Tully discussed this in depth in her presentation on Day 1.

Indirect maneuvers for hands-and-knees:
1. Gluteal lift: Lifting up the mother's gluteal muscles helps release some soft tissue. This is usually used to assist the birth of the head.
2. Forward lift: Firmly push the mom forward; this pushes her pelvis forward and helps the baby’s head release.

Anke concluded by summarizing the key elements of a vaginal breech service:

~~~~~

Q: In Holland we don’t use pelvimetry. Do you let a multip with a small obstetric conjugate still plan a vaginal breech birth?

A: We do MRI scans on women with no proven pelvis. (I.e., that woman wouldn’t have had an MRI at her clinic since she had a "proven pelvis.")

Merry Christmas from the Freezes!

Christmas still happened, despite last-minute renovations, packing, and cleaning. (We're heading back to Nice until mid-July and getting the house ready for our new renters.) Warm weather and sunshine, here we come!

Leonie van Rheenen: Free choice in birth position, change of practice…An obstetrician's point of view

First Amsterdam Breech Conference, Day 2

Leonie van Rheenen

Free choice in birth position, change of practice…

An obstetrician's point of view

One of the "mothers" of the Amsterdam Breech Conference, Leonie van Rheenen is an OB/GYN and is used to working in close collaboration with midwives. The session's announcer noted that for the first time in his life, he's seeing midwives and physicians working and learning together in close cooperation--thanks to this conference. 

Leonie convinced her physician group to shift from supine to all-fours positions in just 6 months. For change management, that’s spectacular--and all due to Leonie's leadership. Leonie and others wanted to learn more, so they initiated this breech conference.

Leonie opened her presentation by saying that her dream has come true: it’s happening and we’re all coming together at this conference. She's already thinking about the next breech conference—possible topics include the 1st stage of labor, monitoring, dilation, trapped heads, and more!

Leonie's presentation was about how an obstetrician came to learn about, accept, and start attending upright breech births. So how did it all begin? Leonie came to work at OLVG. She began as a young OB/GYN, having attended just 7 vaginal breech births during her residency (plus some breech twins and preemies). This hospital had a tradition of breech births and she needed to be able to do them on her own. It gave her some doubts.

They collected numbers on their breech patients. Women have a 60-80% chance of a successful vaginal breech in her hospital. However, most women choose a planned cesarean. Are these numbers (on average, 41 attempted and 28 successful vaginal breech births per year) enough to keep up physicians' experience? She doesn't know.

Leonie needed a mentor to help her with vaginal breech birth. She saw that people were posting clips and videos online and on social media. She saw breech births on all-fours and at home, and it was really new to her. She found out about a course in Sheffield to learn breech skills.

Leonie told a story about being on call when a primip came in labor with a breech baby. At this point she had read about upright breech births and watched YouTube videos, but had never seen one in person. All was going well with a relaxed atmosphere. The mother was standing next to the bed, moving and wiggling her pelvis. She became fully dilated and started pushing. Somewhere during the labor, Leonie asked the mom to go on the bed, and the mom said she didn’t want to. So there Leonie was with this excellent birth, everything going well. The midwife asked Leonie if she was going to ask the woman to lie down on the bed again.

She thought about it. She went through several stages as she considered whether she was okay with attending a breech birth on all fours--something she had never done before:

1. No, never, it's impossible!
2. I don’t see any advantages. Why is it better?
3. How can I learn? How can I get enough experience?
4. What if…

She started to think, There isn’t really evidence for being on your back; it’s more tradition than anything else. But how am I ever going to learn to do breeches on all fours? And on top of that, she was thinking, How can I tell this mom that I’ve never done it before and only have seen it on YouTube?!

She came up with a solution: she placed the mom upright between the stirrups so the mom could stand up and lean over. If Leonie needed to, she could sit her back down. The mom birthed the baby perfectly. She saw the baby do the tummy tuck and, thanks to YouTube videos, she knew the baby wasn’t gasping or in any danger.

Afterward outside the birth room, the birth team gave each other a big High-Five!

Her experience from attending upright breech births:

• Don’t focus on all fours, and don’t start that position too early (especially for primips). Find out what’s best for the woman at that moment.
• Try to find the easiest way and change labor positions.
• Keep the same rules as in lithotomy.
• Train your team. The first time they might be a bit disoriented, but if they’re well trained they’re not nervous and know what to expect.
• Work on exposure/experience: by attending together, use video. Try to get permission to film and share if women are willing. If you have experience, attend with another who doesn’t have that experience. Also get residents there so they can learn.

One of the skills for breech birth is patience. For birth itself is patience!

Leonie also emphasized the importance of teamwork. In her hospital they do obstetric training every week with different teams. She suggested turning your mannequins over and training on all fours.

She showed some videos of upright breech births from her own hospital.

Leonie ended with some advice: the next time you have the opportunity to see an upright breech birth, keep these two things in mind:

• The laboring woman knows best
• You can do it! It’s not so difficult. Worst case, if you feel a bit lost, you can always turn her around and put her in stirrups if that’s how you’ve been trained. You have to start somewhere.

~~~~~

Q: I’m a midwife in the Netherlands. To gain experience with birth on all fours, are you enabling this more for women with head-down babies too at your hospital?
A: Yes, I think so we do. However, I don’t personally attend a lot of spontaneous cephalic births; once I get in there, something’s wrong. We’ve invested in wireless monitoring, which makes it much easier for women to move around. We have birthing balls and a birth pool. We have a lot of midwives working in our ward, so that helps get women out of bed. We're trying to teach our residents as well.

Q: This is not a criticism, more of a comment. We do use wireless CFM but never use a scalp clip because it hurts a baby. What is the prevalence of a Morrow reflex with the clips? My experience with breech birth is that you do pick up the fetal heart very well abdominally even on all fours. They’re a no-no in our trust.
A: I don’t think clips hurt that much. A lot of women don’t want the clip on the baby for the same reason: that it hurts. In the pushing phase, the baby is so deep in the pelvis, we lose the fetal heart rate. That’s when the team starts worrying and wants to intervene. However, if we know that all is going well with the baby, it’s easier for us to keep our hands behind our back.

Interested in Leonie's work? You can follow her on Twitter.

Frank Louwen: Maneuvers for resolving complicated breech birth

First Amsterdam Breech Conference, Day 2

Frank Louwen

Maneuvers for resolving complicated breech birth

Dr. Frank Louwen works at University Hospital of Goethe University, Frankfurt. Other posts about Dr. Louwen include:
The re-invention of vaginal breech birth (Amsterdam 2016)
2nd International Breech Conference, Day 2 (The Germans) (Ottawa, 2009)

He just published the results of 747 singleton term breeches (433 planned vaginal, 314 planned cesarean) at his Frankfurt clinic. See Louwen, F., Daviss, B.-A., Johnson, K. C. and Reitter, A. (2016), Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. Int J Gynecol Obstet. Accepted Author Manuscript.

Knowing the movements of the baby through the pelvis is the most important thing. You compare that to what you see in the actual situation. That’s most important thing—speaking of time and maneuvers. Then you know if there is pathology or not.

How can we detect pathology early and deal with it? Breech birth is like a cephalic birth. We just have to compare what is right or wrong.

Don’t worry about explaining things to yourself. Just know what you expect, what you see, and whether or not it’s normal. With that, we are able to say if we can wait or if we need to do something.

When you first see the buttock of the baby, see where it is. Is the baby above or below the inlet? Is the hip above or below the symphysis? If it’s below the symphysis, the baby will be born very soon. If it’s above, you might have trouble and need a cesarean.

Frank doesn't recommend pushing if there is no contraction. The baby and mother need that time to rest and recover. Don’t use fundal pressure without an indication. In an upright position, the umbilical cord is decompressed and perfusion is fine.

Expect and compare. That is the most important thing.

Timing in breech birth: sometimes you have a hard job to just stand there. Complete breech is less physiological than frank breech, so sometimes they are trickier. Is the baby changing to the next position you expect? Sometimes it’s slower and you have to wait, if all is happening and the baby has good tone/color. Don’t do the Frank’s nudge before the next contraction.

In these pictures, you see the sign of dystocia: baby remaining turned to the side, rather than turned forward. If the mother is upright, the baby shows you that it has a shoulder dystocia. The baby on the left facing forward is normal. The baby on the right has a dystocia with its right arm on the symphysis. If you see that, you know the baby needs help! The child is showing you that there is that problem. If the baby turns facing you, just wait. It will happen.

Louwen’s maneuver is used to resolve this dystocia. Frank’s nudge is used later on to help flex the head if it doesn't emerge spontaneously.

Illustration from Louwen et al. 2016

The easiest maneuver for resolving dystocia is “Louwen’s maneuver:” you turn the shoulder away. To do it, you turn the baby 180° in the direction that the trapped arm is pointing, then 90° back. This gets the shoulders transverse in the inlet. We do this maneuver to turn the shoulders transverse to the inlet. That’s all. The arms might still be above the head after the maneuver, but now that the shoulders are transverse and the baby is in a much better situation. Never pull the baby out. Don’t try to get something deeper. Just move it around until shoulders are in a transverse inlet position. Then you can wait again.

Complete breeches often take longer to descend. The first leg creates a conflict in turning through the pelvis. You can use fundal pressure to see if the baby is descending into the inlet or not. But only do it when needed—you might induce the next pathology, such as a shoulder dystocia. Take the time: compare what you expect and what you really get. Always when you do an intervention, be sure you have a pathological situation first.

For Louwen’s maneuver, it’s easy to move the baby around. You don’t need too much power. Take your time. Put your fingers behind the baby’s shoulders with your thumbs on the shoulders. Don’t move the baby at the hips. You’ll be going inside the vagina—don’t hesitate but do it slowly and calmly. Don’t be afraid. You don’t need an episiotomy. Do it a full 180 degrees, not less. If you don’t finish the full rotation, it won’t work.

Detect the problem and remove the situation.

Based on the outcomes in his Frankfurt clinic, Frank strongly believes that upright breech birth “may provide a physiological advantage to perinatal outcomes compared to the dorsal position. The newly adopted position may decrease manual maneuvers required to extract the body of infants in breech position and resulting birth injuries.” 

Until now, studies have compared well-defined surgical procedures with undefined procedures in vaginal deliveries. He recommends a RCT comparing upright versus dorsal vaginal breech birth.

~~~~~

Q: You said wait for the next contraction until you do Frank’s nudge. But the head is in the pelvis and the uterus provides no pressure.
A: It’s still helpful to have the uterus contracting over the fetal head. Without a contraction, you have no push from above. The head is still inside the uterus and without a contraction you have less power.

Q: When you do Louwen’s maneuver, you do it in between contractions, not during?
A: Yes. Then once the baby is turned, you wait for the next contraction.

Q: In my experience you need a lot of power to turn the baby.
A: Yes, but it will be easier between contractions.

Jane Evans: Mechanisms of Breech Birth

First Amsterdam Breech Conference, Day 2

Jane Evans

Mechanisms of (Upright) Breech Birth

Jane Evans is an independent midwife in the U.K. Other posts about Jane Evans include: Physiological Breech Birth and Cardinal Movements of the Breech Baby (Heads Up! Breech Conference, D.C., 2012)

This conference summary is best understood when watching Jane Evans demonstrate the cardinal movements in person. Fortunately, she gave me permission to film her at the Heads Up! Breech Conference in D.C (2012). Although you cannot see the video footage she had playing in the background, you can still follow the baby's journey as she demonstrates on a doll & pelvis.

I also recommend reading Jane's article Understanding Physiological Breech Birth (PDF) in Essentially MIDIRS Feb 2012 (pages 17-21).



Jane's goal today was to recap what to look for and and what is normal is in a breech birth, particularly when the woman is upright. She has been studying breech for over 20 years. British midwife Mary Cronk first piqued her interest in breech and set up a study day in 2003 after the TBT came out. About 30% of breeches are still undiagnosed at the start of labor, so you’ll need to know how to assist a breech birth: how not to panic, how to help if the baby needs help.

The optimal position for a baby to be in, for breech, is RSA as it drops into the pelvis. In her studies, 55% of breech babies enter RSA while 45% of the babies enter LSA. More babies that come in on the left don’t rotate. Use that observation as a little flag.

As the baby comes into the pelvis--because of the architecture of the bony pelvis, muscles, and ligaments--the baby comes in RSA, comes onto the pelvic floor, and then rotates to RSL or RST. The baby comes down in a straight line. The posterior buttock comes into contact with the mother’s sacrum, and that triggers a lateral flexion of the baby’s hips, which brings the posterior shoulder onto the back and upmost bit of the muscles in the pelvic brim.

That then triggers the baby's rotation back to RSA and continues round to direct sacrum anterior. At the top of the pelvis, that rotation brings the shoulders into line with the widest part of the pelvis. You’ll see the baby’s bum and lower part of the torso.

The body descends and the legs seem to go on forever. The baby is extending its spine. It’s very tempting to flick out the legs, but if you do that the baby won’t have to extend its pelvis so far around the mother’s symphysis pubis, which means the baby will have a harder time bringing its shoulder and head past the sacral prominence. So please don’t flick out the legs!!

As soon as you can see the baby, you won’t be able to hear the heartbeat as easily. Look at the color of the baby. Once the parts are out, look at the tone. Then look at the vitality of the cord. The knees look a bit inside out as the legs are emerging, but that’s normal for newborn anatomy. That facilitates the legs being born. The legs flick out on their own and the shoulders come into the pelvis. You’ll see the “valley of the cord.”

You’ll see a crease in the chest (or "cleavage") indicating that the arms are close to the head and not to worry about. You’ll see the baby siting on the floor/birth bed. Don’t lift the mother’s buttocks and push the mother up at this point!

Sometimes women sit down a bit; this opens the pelvis and flattens the perineum, helping the baby come down. What’s happening inside the woman's body when she does this? At the top, this helps the baby’s head to flex. Do NOT push the mother's bottom up at your peril! (Unless you really need to get the baby out). Sometimes women will move, put a leg up, etc—let her do this.

Now the baby's legs are out and the shoulders are coming in. You’ll see the cord going up through the valley of the cord and going over the shoulder. The cord is quite protected and the baby is not pressing on the mother’s vena cava--another advantage of being upright.

Now with the shoulders, the baby continues to rotate to LSA, and that releases what was the posterior arm (now the anterior arm) under the symphysis pubis. The baby has done its own Loveset maneuver! That allows the posterior arm to drop down. With that, the head drops down into the pelvis. This is where you might get some cord compression.

Then, at this point, Jane and her colleagues had been watching women drop forwards (placing their heads near the floor/bed) and didn't know why. As they were watching photos and videos, they realized that babies are doing a “tummy tuck” at this moment. Often the baby's arms and legs move together, flexing and tucking. If this doesn’t happen at all, you might need to help the baby out. The baby lifts its tummy and arms, tucking its legs, and this movement brings the baby’s chin onto its chest and rolls the occiput onto the mother’s symphsis pubis. It doesn’t hurt the women, but they all say at this moment: “I had to move.” They drop their torso around forward and roll their pelvis around the baby.

Now all that’s holding the baby in is the pelvic floor muscles and the perineum. Plomp! Out comes baby.

Once the baby is born, follow the curve of the mother's sacrum and pass the baby through the mother's knees to the mother. Then, if needed, you can assess the baby from the other side.

The first Apgar score is taken at 1 minute. That can be a long time to wait. Breech babies are a bit like waterbirth babies. Leave them there. Don’t cut the cord! You still have the circulation going from the placenta. The babies will often lie there, quite happily, nice and pink, and then suddenly open up and breathe.

When the baby comes down LSA (about 45% of breeches), what you should be seeing for normal is mostly the same but on the left rather than on the right.

Shawn Walker: Supporting breech birth within a paradigm of complex normality

First Amsterdam Breech Conference, Day 2

Shawn Walker, RM, MA, PhD cand.

Developing health professionals to support breech birth 
within a paradigm of complex normality

Shawn Walker is a registered midwife in the UK and a PhD candidate. She worked as a Breech Specialist Midwife in a NHS breech clinic and has attended births in homes, birth centers, and hospitals. Her PhD research focuses on upright breech birth.








Shawn opened her presentation with an extended analogy:

       In a parallel universe, imagine that 96% of babies are born bottom-first, and everyone knows all the variations of breech. Occasionally there are tricky situations and that’s where consultant OBs jump in.
       But then there are these 4% of babies presenting head-first that cause all sorts of trouble. Occasionally their heads come out and their shoulders don’t follow and panic ensures. And then someone gets the idea of having a term vertex trial, and it turns out the cesarean is safer than vertex birth. Gradually—because brachial plexus injury for shoulder dystocia is 1/20—cesarean becomes the standard of care for head-down babies.
       The occasional radical midwife makes trouble, suggesting that we go back to basics and look at the physiology of what happens when women direct their own births. Nope, OBs suggest it’s an obstetric issue; midwives shouldn’t be involved since they can’t provide the complete package of care.
       And then a very powerful and well-connected OB was having a telephone conversation and he saw a picture of someone doing axial traction to deliver the shoulders. He thought, let’s put women with vertex babies in upright positions where they can move and see what happens. And then another troublemaker in Canada proposed that midwives should be involved in vertex births because they have smaller hands and don’t even need to cut episiotomies. And so began the Small Hands Revolution!
       And then some researchers presented their data from all around the world insisting the data is clear that vertex is not as safe, but we must still have shared decision-making. And for that choice to be available, we must have access to the safest possible care. But we still feel vulnerable—how can we make it safer? Then a visionary said, “Look, it’s the 21st century. Birth is safer than it’s ever been—why can’t we do the same for vertex birth? How can we help each other feel less vulnerable?”

(If you hadn't noticed it already, Shawn just summarized Day 1 of the Amsterdam Breech Conference!)

Shawn then argued that there’s a paradigm shift going on to seeing breech as a complex normality, rather than an abnormality.

What is required to become competent in breech?
Shawn's recent article, Standards for maternity care professionals attending planned upright breech births (Midwifery Mar 2016) "establishe[d] a consensus of opinion on standards of competence for professionals attending upright breech births." The key elements are:

1. Hands-on simulation (skills and drills)
2. Regular opportunities to discuss with peers and mentors
3. Watching breech birth videos
4. Theoretical instruction in anatomy, physiology, mechanisms, and maneuvers
5. Mentorship and supervision in clinical settings

We can use videos of breech births to enable pattern recognition. What does that mean? When you attend a high number of births, you begin to recognize certain patterns. Shawn showed two side-by-side births. Both had good outcomes, with one being completely normal and the other right on the border of needing intervention.

We need to know what normal looks like (sternal crease or “cleavage," baby's body facing straight) versus what needs help (baby's body facing sideways).

Videos are great for practicing clinical decision-making. Shawn likes to play “save the baby.” Colleagues chime in while watching videos and say what should be done to help in a tricky situation. When you see signs of trouble--because you already know the signs and patterns of normal--you can then confidently step in and help a baby that can’t birth by itself.

Shawn also does Breech Study Days all around the world. Core elements of her physiological breech birth training include

1. Research updates—counselling is a skill
2. Teaching what is “normal for breech:” mechanisms, other features
3. Complicated Breech Births: skills and maneuvers
4. Simulations and case scenarios

When all is well, respect the mechanism

When all is not well, restore the mechanism

Shawn's online Moodle space facilitates great discussions among care providers all around the world and lets members share and compare videos. A new video is released each month to simulate the process of attending a breech birth regularly. Study Day participants get 1 year free access.

Shawn has also been evaluating her teaching, especially levels of confidence in her trainees before & after the training. She has found significantly increased confidence levels post-training.

We desperately need research evaluating real outcomes after breech skills training, not just confidence levels. She noted that PROMPT excludes outcomes of vaginal breech babies in their evaluation. Shawn will be evaluating this aspect from her recent training sessions in North America, doing a 1-year followup to see if there has been a change in behavior and outcomes, in addition to confidence levels.

Shawn also noted that obstetric emergency breech training does not lead to an increase in rates of vaginal breech births; it actually makes the rate go down. Can we make the rate of vaginal breech births go up? She’s also doing a visit to Auckland in the fall and collecting before/after data. She requested that if you’re doing breech teaching, please collaborate with hospitals to gather before & after data.

The most interesting question, Shawn remarked, is, Can we make breech birth safer?

~~~~~

Q from Andrew Bisits: Regarding the emphasis on mechanics, clearly I agree . It’s doable because we do and can understand the mechanics. However, the other part of making it safer is the oxygenation issue, particularly in the 2nd stage. There are unknowns in this aspect in how a baby copes. What are your thoughts about that area?
A: Regarding oxygenation and how we teach people how to evaluation fetal well being in 2nd stage and make decisions: when you’re a HB midwife and you start out, you have a higher transfer rate a the beginning. I maintain that 3-5 minutes from the umbilicus to birth is a great starting place (but it wasn’t approved by my consensus panel) because when you’re an expert, you have more intuitive knowledge and thus more time to play with. Novices need to be taught good methods: not to intervene too soon, but to be assertive with time if there isn’t clear evidence of good fetal well-being.

Q from a Dutch OB: It's really good for us to hear about your parallel universe and it made everything so clear at once. Two things about the videos: 1) cleavage: if you see the baby’s chest with a crease, that means the arms are close by and you just need to wait for another contraction. If you see a flat chest, you need to help the arms. 2) Meconium: not a sign of fetal distress in a breech. Tell your nurses and other staff there for the first time so they don’t worry about it. Be happy about the meconium—it’s a great sign in a breech birth.
A: Yes, in a full-day training course, that’s absolutely what we go over. Also tell your nurses, 2nd midwife, etc, that fresh mec is different from mec stained waters. Don’t document fresh mec as mec stained waters.

Q from Anke Reitter: Even if the baby seems to do all the right things, babies that have been compromised in 2nd stage will not help with the process and will look different (no tone, etc.). They need active hands-on. It’s like doing a cesarean on a baby with little or no tone.

Q: If you talk about making birth safer and about counseling, how do you involve the mother to make birth safer because she’s birthing her baby? How in your experience does it work better if the mother is fully involved?
A: You do have an obligation to share these numbers with them, though as Andrew Bisits remarked it can be complicated. As Floortje Vlemmix said, she asks women “What are you thinking about?” or “What do you know?” I also use videos to show women so they have an idea of how normal breech works. I also talk about what I'd do in complications and what I might say and what it means—so the woman understands beforehand.

Q: Do you find that if women have more confidence, it actually works better? Does her instinctive behavior help?
A: The movement to create breech specialist clinics is very very good. I will keep promoting that. I was a breech specialist midwife and I counseled everyone with a breech presentation. The women who’d come through my clinic chose VBB at a same rate as Dutch data (around 30 is %). Those women had easier births than women who came from outside with conflicted situations, who had to fight for their breech births. Sometimes they didn't know when to stop fighting. We should not make women fight for what they want.

Q from a Dutch obstetric resident: After hearing your alternate paradigm universe [in which breech is normal and head-down is uncommon], we are feeling so convinced to do it on all fours. Then we go out in our practice and we have colleagues who haven’t been to this conference. Should we try to convince our colleagues? No, instead we should gather together and carefully evaluate the short and long-term consequences of what we’re doing.
A: Definitely. To a certain extent, these techniques have been well-evaluated (for example, with Frank Louwen's study). Also, you cannot evaluate something until someone becomes competent in it--one of the problems with the TBT. Until you actually practice it, you cannot evaluate it properly. There’s a certain amount of latitude that experienced professionals have to say “This makes sense and I would like to try it.” You should certainly come together to help other people make those transitions, to help them get over the learning curve.

Q: May I add something: After this conference, we agree that the Netherlands is a small land. We can easily start here in Amsterdam. Our hospitals are on board to work together to help women to find the right place and to have those options. It’s easy to evaluate because you can do the births together and film them. We will do that here.

Day 2 Welcoming Speech at the First Amsterdam Breech Conference

First Amsterdam Breech Conference, Day 2

Welcoming Speech

Ruth Evers

Courage is a quality of mind or spirit that enables a person to face difficulty, danger, or pain. Courage ins’t seeing what you want to see and proving to the world that you’re right. Courage is looking at all sides of the matter and being brave enough that you realize you might need to change your ways because you allowed yourself new insights and a new paradigm.

Thanks to Gail Tully showing us videos of breech births that were not so easy. Thanks to Floortje Vlemmix for talking about subsequent births after the breech birth and for acknowledging that we’re not so sure what’s right and what’s wrong. Thanks to Frank Louwen for telling us that almost everything we do in daily practice is outdated and that putting women on their backs is an intervention.

Today we’re going to build courage as we do hands-on training and learn how to do a breech birth on all fours.

Ruth concluded her introduction with a brief excerpt from the documentary A Breech In The System.

Expert Panel Q&A at the Amsterdam Breech Conference

First Amsterdam Breech Conference, Day 1

Expert Panel Q&A

Q: I have a question about the article by Thornton et al, referenced by Floortje Vlemmix, that argues that cesarean for breech is clearly beneficial. I have a question about some of the data.
Betty-Anne Daviss answered. (I didn't catch all of her answer, but she discussed the Canadian registry study.)

Q: I have a question about the experience levels of OBs or midwives doing vaginal breeches. Most guidelines suggest experienced practitioners. What do panel members define as experienced? Any factors/parameters that qualify?
Frank Louwen: You have to attend some VBBs, but initially you should watch videos over and over. This is more important than just attending the births. Watch videos: not just the last 10 minutes of the birth, but from the beginning of the labor.

Q: You have to attend many VBBs to be able to identify pathology.
Frank Louwen: We’re always seeing CS and VBB compared without a closer look at the vaginal breeches. What is a real risk for VBB? Once we can point those out, then we can really reduce mortality and morbidity. I've been able to reduce complication rates by more closely looking at the woman and child.
Rebekka Visser: There are cultural differences in hospitals in how they do breeches. For example, what about shoulder dystocia? Some providers have higher instances than others, which points to the complications arising, in part, from what providers are doing. Numbers don’t say everything.
Marjolein Kok: Not many people can speak of real experience here in the Netherlands. You need to know how to solve problems. How? Practice on a mannequin.
Betty-Anne Daviss: We should do a randomized controlled trial on the effects of fear. Fearful people do very crazy, dangerous things. In Canada, we have a 10-15 year break in OBs who used to do VBB, stopped doing it, and then just started doing it again. So they are very fearful because they haven’t done it for a long time, and they act based on that fear. How does fear affect clinical practice?

Q from an OB: Nowadays women are so fearful and anxious to choose a VBB because they worry about regretting it afterwards. How can we counsel women so they have more trust in delivering safely with a VBB? Use other language? Other suggestions how we can counsel women better so they don’t make decisions out of fear or regret?
Andrew Bisits: We do present numbers, but we also are dealing with a generation of women who’ve never been healthier. I’d say this to a woman with a breech baby: “I am confident that I think it would go well for you.” It’s unfortunate that there’s such a fear when, really, whatever we do is safe. We’re dealing with such small numbers now. We’re not going to have a hope in hell unless we do address that. We ourselves need to reclaim confidence in our own skills.
Leonie van Rheenen: Many women have already made their decision by time they come in to see us. Maybe we need a Kim Kardashian who’s done a VBB!

Q: I’m an OB. I've done over 3,000 cesareans and just about 100 VBBs. I am scared with VBBs, even though I do support that choice. Do you support that quote I asked about earlier? (I think he was referencing Thornton et al.)
Frank Louwen: If I had the complication rates reported in the TBT in my own clinic in Germany, I wouldn’t work anymore. I’d be in jail! I am completely convinced that just giving the women the information about the TBT—that they compared different settings, situations, etc—will show that the cesarean was never an answer to complication rates in breech deliveries. It’s not an existing answer for our counseling of women. In Germany, we don’t understand why people are still looking to that trial, as Marek Glezerman pointed out.

Thomas van den Akker: Who pays the price? (Foreign) women, future siblings

First Amsterdam Breech Conference, Day 1

Thomas van den Akker, MD PhD

Who pays the price? (Foreign) women, future siblings

Thomas van den Akker, MD PhD, is an obstetrician at Leiden University Medical Center. The slides from his presentation are available here.

Of all the presentations during the 2-day-long conference, Thomas van den Akker's was the most powerful and most memorable. Future siblings and foreign women are now paying the price for Western countries' fear of breech.

Thomas opened with the comment that “not every breech delivery is a hallelujah delivery.” He doesn’t have a clean record like Dr. Frank Louwen. But he’s still here to defend the option of a vaginal breech birth. His only conflict of interest is the woman in a faraway land who might pay the price for our fear of the breech.

He’s not a fan of the 2000 Hannah Term Breech Trial because it has a flawed data set. But assuming that the TBT is true and not flawed, what are the outcomes of a policy of universal cesarean for breech presentation? For term breech babies in the Netherlands, the Number Needed to Treat (NNT) comes to 338 based on a 2014 study by Vlemmix et al. In other words, doctors needed to perform 338 cesareans to save one breech baby’s life. However, looking only at these numbers is shortsighted (for one example of shortsightedness, he pointed to this 2015 article by Joseph et al in Obstetrics and Gynecology).

What do you miss when you only look at the NNT?

1. The mother
2. Subsequent pregnancies
3. The rest of the world—much of the rest of the world is really missing from the conclusions and ramifications of the Term Breech Trial, such as remote hospitals far away from urban centers.

These three questions are hard to answer because there’s under-reporting of adverse outcomes, limited and/or little long-term follow-up on the mothers and babies, and fear of litigation.

The TBT gives a very limited answer about maternal morbidity.

Figures from the Netherlands give us a better look at how a policy of cesarean affects women. These figures are clear: severe acute maternal morbidity is higher with cesarean section than with vaginal breech birth. Peripartum hysterectomy is higher in the cesarean groups. (See Van Dillen et al. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstetrica 2010).

Between 2000-2002, four Dutch women died after having an elective cesarean section for breech, which comprised 7% of the Netherlands’ direct maternal mortality. (See Schutte et al. Maternal Deaths after elective caesarean for breech presentation in the Netherlands. Acta Obstetrica 2007.)

Thomas reiterated that if we do a lot of cesareans, some women are going to die from them. Others will be injured in the short term.

There are also long-term consequences from cesarean sections for breech. Maternal morbidity in subsequent pregnancies is higher.

Perinatal death is subsequent pregnancies is higher.

Again, from the Dutch data, for every 10,000 babies delivered by elective cesarean section for breech, 26 will be saved in that pregnancy. But...27 babies will be lost when the woman has her next baby, assuming a policy of VBAC. 

This raises an ethical question: Does performing 997 elective cesarean sections justify saving the lives of 3 babies? What about the costs?

In our context (resource-rich, developed world, easy access to hospitals), the difference in outcomes for a mother's first child is small. But there are enormous consequences of a cesarean-only policy in other parts of the world.

Remember the NNT of 338? (338 elective cesareans for breech presentation needed to prevent one fetal death.) In other parts of the world, the dangers of cesarean sections are amplified. In Tanzania, those 338 cesareans would result in 6 maternal deaths. In a district hospital in Malawi, 3 women would die for every one baby saved. And that’s just in the short run. (See Van Roosmalen and van den Akker BJOG 2014 and Van Roosmalen Lancet 2014).

In addition, fertility rates can be much higher than in the Western World, so the impact of that cesarean section for breech is multiplied.

Thomas concluded that our messages about breech are doing harm elsewhere. We need to take into account a woman’s complete fertile life, especially if she’s living in more dangerous circumstances where cesareans are much less safe than they are in developed countries. Dealing with a breech is not simply black and white.

~~~~~

Q (Australian OB Andrew Bisits): Women have difficulty processing these numbers, but even for us OBs it’s difficult. How do we know that what we are presenting is comprehensible? Women are processing not just the numbers, but a whole lot of other factors that go into their decisions.
We’re dealing with very small numbers of adverse events. We should at least be able to learn something from the adverse events to make things even safer.
A: Yes, agreed completely. We should take into account adverse events, but in a much wider context and setting. We need to give the other numbers—the ones I presented today—to confront people pushing ECS for all breeches.

New Study: Facilitating Vaginal Breech Birth in Hospital Settings

I am excited to announce my latest research project: examining what helps and what hinders vaginal breech birth in American hospitals.

I am actively recruiting hospital-based breech providers to participate in a 30-60 minute phone or Skype interview. This includes providers who have attended vaginal breeches within the past 10 years, even if they are no longer doing them today.

I am also hoping to study one or more maternity units that currently support the option of vaginal breech. Finally, I will be interviewing allied health care providers who have had some interaction with vaginal breech births (L&D nurses, anesthesiologists, and pediatricians).

If you would like to participate, or if you can recommend someone who might be interested, please
contact me. 

More information below:

~~~~

Principal Investigator: Rixa Freeze, PhD
Collaborator: Shawn Walker, RM, MA, City University of London
Name of Project: Facilitating Vaginal Breech Birth in Hospital Settings

1. Purpose of the study

Despite the shift towards cesarean for breech presentation after the 2000 Hannah Term Breech Trial, some providers and hospitals continue to support the option of a vaginal breech birth. Our study examines the barriers and facilitators to providing a sustainable hospital-based vaginal breech service in the United States. We are studying maternity units as well as individual maternity care providers and allied health care providers (such as pediatricians, L&D nurses, and anesthesiologists) to understand the obstacles they face and the lessons they have learned in providing vaginal breech birth.

We theorize that the hospital environment—such as supportive colleagues or policies that uphold patient choice and autonomy—can significantly affect a provider’s willingness and ability to provide vaginal breech birth. By understanding both the obstacles and the supportive practices, we can help hospitals and providers better facilitate vaginal breech birth now and in the future.

2. Description of procedures and approximate duration

Participation in this study will involve an interview with one of the researchers. You will answer a series of open-ended questions about your experiences with vaginal breech birth. Interviews will be done in-person when possible, otherwise by phone or Skype. Interviews will be recorded and transcribed to ensure accuracy. Your name and location will be kept anonymous.

Participation in this study should take approximately 30-60 minutes. If we have additional follow-up questions, we will contact you via email or telephone.

3. Description of the discomforts, inconveniences, and/or risks that can be reasonably expected as a result of participation in this study.

There are no risks associated with this experiment beyond what you would encounter in everyday life. This study does not involve deception.

4. Anticipated benefits resulting from this study

We anticipate using our research to create a set of guidelines for hospitals and providers wishing to support vaginal breech births. This may benefit you directly by providing support and guidance; it may also benefit other providers and hospitals who wish to preserve the option of a vaginal breech birth. Keeping vaginal breech birth alive can help reduce the national cesarean rate, support maternal autonomy, and ensure that maternity care providers retain a valuable skillset.

5. Contact information

If you have questions about this study, you may contact:

Rixa Freeze  (765-323-8098) or Shawn Walker