Friday, September 15, 2017

Breech birth in the developing world

Image from Giving birth--the most dangerous thing an African woman can do?
In resource-rich countries, the debate about how to best deliver breech baby is largely focused on reducing a very small risk of death or serious disability at the price of increased maternal mortality and morbidity and problems in future pregnancies. However, in the developing world, the debate around breech has a unique set of implications and consequences. In resource-poor countries, perinatal mortality rates are often high, health infrastructure is low, and providing even basic care to all pregnant women is a challenge. Cultural values about vaginal birth and attitudes towards cesarean sections may also differ from the developed world.

Below are excerpts from several articles published after the 2000 Term Breech Trial that examine breech birth in developing countries. (I was working alphabetically through my reference list. I started compiling excerpts while on letter "I," hence the lack of authors from A-H).

Igwegbe AO, Monago EN, Ugboaja JO. Caesarean versus Vaginal Delivery for Term Breech Presentation: A Comparative Analysis. African Journal of Biomedical Research 2010; 13(1) Full text here.
The implication of this finding is that in well selected patients, neonatal outcome following assisted vaginal breech delivery and planned caesarean section may not be different. Owing to the high level of aversion to caesarean section by our women (Aziken et al., 2007; Ezechi et al., 2004), as well as the associated surgical risks, a whole scale policy of caesarean section for all cases of term breech delivery may not be feasible in our environment. Moreover, the policy will inevitably lead to an overall increase in caesarean section which will put a strain on the very limited resources in the region. As breech presentation is not a recurrent indication for caesarean section, most of these women who had caesarean section will attempt vaginal delivery in their subsequent pregnancies with the associated risk of uterine rupture. Owing to the very high premium placed on vaginal delivery by the African women and the fear of a repeat caesarean section, a significant number of these women may not present to a proper health facility for management. The consequence is increased likelihood of uterine rupture and the attendant maternal mortality and morbidity.

Furthermore, in Africa, labour and delivery are not just medical matters, but carry a huge cultural significance. Any intervention that will affect the attitude of the people towards labour and delivery must consider the cultural aspect.

Mishra M, Sinha P. Does caesarean section provide the best outcome for mother and baby in breech presentation? A perspective from the developing world. J Obstet Gynaecol. 2011 Aug;31(6):495-8.
It is impossible to deliver all term breeches by CS, as a systematic review has suggested 9% of women still have a vaginal breech delivery (Conde-Agudelo 2003). This is due to: maternal request; advanced or precipitate labour; or the presence of a second fetus in twins. This further highlights that the obstetrician providing intrapartum care should be able to conduct vaginal breech delivery....

Obstetricians are trying to follow the guidelines provided by the Royal College and are adopting a policy of CS as recommended. However, the short- and long-term maternal complications and the effects on family and society, which have huge emotional and economical implications, are ignored. The impact on women of developing countries has not been considered thoroughly and data have not been compared against developed countries. These developing nations are still struggling to provide basic antenatal care to mothers and reduce the maternal mortality rates (MMR). In 2005, the MMR in India was 450 per 100,000 in stark contrast to developed regions (9 per 100,000)….However, a significant decline in perinatal mortality has not been seen, despite the high CS rate in recent years and decrease in vaginal breech deliveries from 70.4% in 1994 to 13.1% in 2004....

[O]ffering CS to all patients does not improve the neonatal outcome significantly. This study highlights that case selection for planned vaginal deliveries is still a viable option.

Recently, it has been highlighted that CS is not always safe and is associated with severe maternal morbidity. In developing countries where anaemia is prevalent and blood and blood products are not readily available, abdominal delivery further contributes to high morbidity and mortality. There is a lack of support for the women, society and cultural values are different and health economy is of paramount importance....

For possible small improvements in perinatal outcomes, the impact and consequences of CS on future pregnancies in women who do not understand the benefits of antenatal care is more risky than vaginal breech deliveries....

Vaginal breech deliveries cannot always be avoided and will continue to occur, even in institutions with a policy of routine CS deliveries. There are situations such as precipitate delivery, home birth, fetal anomaly or fetal death and mother’s preference for vaginal birth. As a result, it is essential for clinicians to maintain the skills needed for breech deliveries. Moreover, at the hospital catering for this kind of population, several patients will continue to choose vaginal breech delivery....

CS section should be performed in selected cases after full consideration and with the involvement of the patient and their relatives and where appropriate, with a clear indication and aim of what is going to be achieved. It is ironic that where maternal morbidity and mortality is very high we are concentrating on a very small subset to reduce the perinatal morbidity and mortality. This study highlights that vaginal breech delivery remains a viable option in some patients and should be discussed with patients with a full explanation. They might choose maternal health as a priority and accept the small risk to the neonate. [Emphasis mine]

Mohammed NB1, NoorAli R, Anandakumar C, Qureshi RN, Luby S. Management trend and safety of vaginal delivery for term breech fetuses in a tertiary care hospital of Karachi, Pakistan. J Perinat Med. 2001;29(3):250-9.
Vaginal birth is generally considered better for mothers than cesarean section, as one avoids the operative complications associated with major abdominal surgery and an increased cost of birth. In developed countries, the risk of maternal death due to cesarean delivery is 2 to 30 times higher than that observed with the vaginal births. However, in developing countries, these figures are alarming, where there are 3-6 maternal deaths for every 1000 cesarean deliveries and where every eighth in-hospital maternal death is attributed to cesarean section. Moreover, trial of scar is associated with the risk of uterine rupture (7/1000) and there is a significantly greater post-partum morbidity after repeat cesarean section than after a vaginal delivery.

In Pakistan, this issue is further complicated by the lack of adequate documentation about the indication for the previous cesarean section, the stage of labor at which it was performed, the type of uterine incision and the course of post-operative morbidity/recovery. Moreover, the patient’s desire to avoid cesarean birth due to social pressure may result in avoidance of antenatal care and hospital deliveries in subsequent pregnancies. As more and more obstetricians turn towards elective cesarean section as delivery mode of choice for breech infants, the trainee obstetricians would loose [sic] the opportunity to acquire skills for safe vaginal birth, with the resultant loss of this delivery option to be offered to the parents.

Orji EO, Ajenifuja KO. Planned vaginal delivery versus Caesarean section for breech presentation in Ile-Ife, Nigeria. East Afr Med J. 2003 Nov;80(11):589-91.
[T]he policy of wholesale Caesarean section for delivery of term breech infants as being advocated and practiced in many centers in developed countries needs re-appraisal. There is no clear benefit of abdominal delivery where strict selection criteria is employed...increased maternal morbidity attending abdominal delivery would make Caesarean delivery a less favourable option, especially in our environment where there is a great aversion to Caesarean section and where the woman cannot be guaranteed to report for monitoring in subsequent pregnancy if at all such monitoring facility is widely available.

Sobande AA1, Archibong EI, Abdelmoneim I, Albar HM. Changing patterns in the management and outcome of breech presentation over a 7-year period. Review from a referral hospital in Saudi Arabia. J Obstet Gynaecol. 2003 Jan;23(1):34-7.
However, the meta-analysis by Hofmeyr and Hannah (2001), which alluded to the findings of previous authors [Golfier 2001, Herbst 2001, Hannah 2000], did not assess the cost and future morbidity as a result of the caesarean section scar. This will be very relevant in our society, where grandmultiparity is common and patients may be having their 6th or 7th caesarean section….

Although it may be difficult to elucidate clearly the reasons for these changes, there is no doubt about the fact that the preferred route of delivery of a singleton breech at term is by elective caesarean section in the developed world. Perhaps we need to consider whether it is necessary to follow management trends elsewhere in the world without taking cognisance of the culture of the society in which we practice…. [Emphasis mine]

Our community, being a developing one, still prides itself on the size of the family and, as such, it seems logical to try to allow vaginal delivery in breeches with the safety of the mother and baby still the priority. With a sizable proportion of childbearing women in our society being grandmultiparae, the risks of repeat caesarean section especially placenta praevia accrete increases. It was shown by Zaki et al. (1998) that the incidence of emergency hysterectomy in cases of placenta praevia accreta was 50% compared to 2% in non-accreta. It will therefore seem reasonable to attempt to reduce the trend of caesarean section for breeches in our community….

This study showed no birth trauma in 1997 while birth trauma resulting from breech delivery was highest during 2000. This may be due to the quality and experience of the registrars working in the department at the specific periods in time.

van Bogaert LJ, Misra A. Neonatal outcomes after vaginal and caesarean breech delivery. S Afr Med J. 2007 Oct;97(10):949.
In developing world settings, and especially in rural conditions, a proper management plan before the onset of labour is often not achievable. The unpopularity of the prospect of a CS prompts women to delay admission to the labour ward until in established labour.

van Eygen L1, Rutgers S. Caesarean section as preferred mode of delivery in term breech presentations is not a realistic option in rural Zimbabwe. Trop Doct. 2008 Jan;38(1):36-9.
Increasing the number of CS should be strongly discouraged since the case fatality rate in this rural setting was found to be very high: 18/1093 women died after CS (for any indication) within 42 days after the operation (1.6%); 15 within 24 h. Haemorrhage was the major cause of death....

[The very high case fatality rate of 1.6% for CS] is a reason for great concern. We calculate that delivering 1000 babies in breech presentation by CS (excluding those whose outcome cannot be influenced by labour management) would save 137 babies, while 16 mothers would die as a result of the operation. Assuming that each woman will have two more deliveries and one third of these will be by CS, this policy would cause 656 (984 x 2/3) additional CS in the future, and 11 more maternal deaths, and this does not include the women who will die from a ruptured uterus during a subsequent pregnancy before they can have a repeat CS. Therefore, delivering all term breech presentations by CS would save 137 babies, but at least 27 women would die. In our view, this is totally unacceptable. In addition, orphaned babies also have a high risk of dying....

In this rural setting only a minority of women deliver in district hospitals. Thus, women with an easy vaginal breech delivery (at home or in a clinic) resulting in a live baby were not taken into account in this study. If all breech presentations at term were delivered by CS, then even more CS would be performed but at a lower percentage of babies would benefit.

The lack of correlation between the BrPNMR [breech-related perinatal mortality rate] and the CS rate, and the high mortality rate after CS, make a strong case against the systematic delivery of [breech presentations] by CS in this setting. Rather, attention should be given to improving the overall management of breech deliveries.
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Tuesday, August 29, 2017

A physiological breech birth in Brazil

This gorgeous upright breech birth is worth the time to watch. The mama had originally planned a home birth, but transferred in labor to a hospital due to breech presentation. I loved watching the OB's face as she is sitting at the foot of the bed. I imagine she is thinking "Best. Day. Ever!!!"

For a faster sneak preview, start the player at 6:15. You'll see the baby following all the cardinal movements of an upright breech:
  • Body rotates from transverse to facing straight towards the attendant ("tum to bum" as they say in the UK)
  • Legs go on forever, knees look turned almost inside-out, and then plop out 
  • Chest crease or "cleavage" indicates arms will soon follow
  • Baby does a tummy tuck once to release its arms and once again to flex its head
This all happens so quickly that the filmmaker put the birth in slow motion.



Here is the Google Translate version of the birth, taken from the YouTube page:
Thayla was born on a rainy Sunday in May 2017. The initial plan was a home birth, but she was breech (with her butt down and her head up), so it was recommended that she be born in a hospital. The family stayed at home accompanied by midwives Paula Leal and Silvia Briani of Mamatoto team and doula Thais Olardi, until her mother, Thais, was 7 cm dilated. In this hour they went to the Hospital and Maternidade Sepaco where, after a short time, Thayla was born in a totally natural way, without any intervention, in a respectful and humanized way. In the hospital the family received the support of the obstetrician Camila Escudeiro and the neonatal pediatrician Nicole Martin.

It is with great generosity that the family opens up their intimacy and discloses the video of the birth of Thayla. Parents believe that good stories deserve to be told and that it is indeed possible for pelvic babies to be born naturally. The biggest message that Thais leaves to all mothers is: "Believe in yourself, believe in the strength and perfection of your bodies!"

Clareou Films took great pleasure in following this story and is flattered to share with you a story of faith, determination and a beautiful happy ending!

Congratulations to the dads and thank you for sharing this special moment in your life with other families! Welcome, Thayla

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Saturday, August 26, 2017

Why do I care about breech so much?

This letter explains why I want vaginal breech birth to remain a viable option for all women. It was originally written to a member of the Coalition for Breech Birth Facebook group and shared with permission. (I added paragraph breaks for readability.)

~~~~~

Hi F___, I found your posts that had the hashtag "forcedcesareans." I searched it because I feel like very few people understand the pain I'm going through. I had a forced c-section because my baby was frank breech. I knew vaginal was possible, and that it happens in many European countries (hospitals too). I live in WA, and as anywhere else in the US, hospitals don't allow vaginal breech. I felt completely trapped, I wanted to run away before the scheduled surgery but I couldn't because I've been showered with scare tactics by the doctors.

The day of the surgery was a complete nightmare and I was in shock and scared the whole time. I felt like dying while the needle was entering my spine. "When you'll see your baby it won't matter", they said. And it didn't for a couple of minutes, because I was drugged and tired of fighting over what was no longer my pregnancy. But then I stopped taking opioids (I had to have an unmedicated birth... I didn't want anything like that! I wanted at least to go into labor...), the pain became less intense and anger grew inside of me.

I still feel angry and I feel like it's growing everyday. I still have flashbacks that some days are very frequent. And I feel angry and desperate and lost. They all knew. Everyone knew I absolutely did not want this. I cried at every appointment since the word "breech" was mentioned. I cried every day in between, and after, especially as the physical pain was decreasing, leaving space for more anger. I do not trust hospitals anymore. I hate my body now. I was loving it. I was loving my pregnancy until then. Now I feel like half a person. I have a baby but I didn't give birth. And no, I didn't. Every time I hear someone who's never had it done say "it's the same, a friend of mine had both vaginal and cs and she said there's no difference!" I get angry. I hate everything about it.

I don't trust hospitals anymore, at least not for birthing. When they saw I was in despair they kept repeating me next time I cod go for a VBAC. They were already planning my next pregnancy, exacerbating the feeling that what I was living wasn't my pregnancy anymore, and the next one too (the hospital being more TOLAC friendly than VBAC. What a joke.). They also made me feel inadequate because my baby was too sleepy from my opioid-tainted colostrum and she lost 11% of her birth weight, telling me I had to integrate with formula as my nipples were also sore.

I'll never forget what a horrible thing was done to me, all because of hospital policy and the lack of expertise. Because of their limits I had to be sliced open, had my baby removed from my body before labor even started, leaving me deeply traumatized, emotionally and physically broken, afraid of my own body and worried about my future pregnancy. I will have to report the surgery even if I will have to go to the dentist, reminding me every time that my bodily integrity is gone forever. All because my baby was head up.

Sorry for the long message... I just need to communicate how painful and horrible it is to prevent a woman from doing something so natural that her body needs. It messed up my psyche and I feel anguished about surgical birth unless strictly necessary. Thanks for reading... ❤️
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Thursday, August 24, 2017

The Tsovyanov maneuvers for frank and footling breech

I discovered two maneuvers for assisting frank and footling breeches while wading through PubMed literature on breech from the 1950s. I've never heard of anything like it before. It was introduced by N.A. Tsov'ianov in the Russian medical journal Sovetskaia Meditsina in 1951 in an article titled New method of conduction of labor in breech presentation.

Tsov'ianov (also spelled Tsovyanov) apparently introduced two maneuvers. Maneuver I was for frank breech presentations; maneuver II was for footlings.

I'm having a hard time finding details about these maneuvers, since all of the articles are in Russian and the references on PubMed do not include abstracts. However, I did find this website about breech pregnancy and birth written hosted by Ternopil State Medical University in the Ukraine and written by I. Kuziv. A friend of mine living in Russia, Katerina Perkhova, sent me the illustrations.

Here is Kuziv's summary of the "Tsovyanov I" maneuver for breech breech babies:
The manual aid by Tsovyanov I in frank breech presentations.

The aim of the manual aid: to prepare the maternal ways to the delivery of the head and shoulders and to keep the normal attitude of the fetus.

In the frank breech presentation the fetus extremities are flexed at the hips and extended at the knees and thus the feet lie in close proximity to the head. The circumference of the thorax with the crossing on it arms and legs is larger than circumference of the head and the after-coming head deliveries easily.

The technique. The aid begins after the delivery of the buttocks. The obstetrician’s hands are applied over the buttocks, the thumbs placed on the fetus sacrum and other fingers on the legs. The doctor gently supports the legs to avoid its flexion. If the normal attitude of the fetus is keeping the head deliveries easy.


It appears that the attendant holds the legs against the torso, keeping the feet near the head for as long as possible.

Here is Kuziv's summary of the "Tsovyanov II" maneuver for footling breech babies.
The manual aid by Tsovyanov II in footling presentations.

The aim of the manual aid: To perform [convert?] the footling presentation to the incomplete breech and to prepare the maternal ways to the delivery of the head and shoulders.

The doctor covers the area of the vulva with the sterile napkin and puts up resistance to the delivery of the feet. The feet are flexing and the footling presentation becomes incomplete breech presentation. Than the delivery manage as in incomplete breech presentation.

I think the author means that this second technique converts a footling presentation into a presentation where one or both hips are flexed. "Preparing the maternal ways" refers to creating a large enough diameter in the fetal presenting parts for the fetal head to pass through easily.

Thoughts? Comments? Are the Tsovyanov methods still taught in Russia, the Ukraine, or other countries in that region?
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Wednesday, August 23, 2017

Physiologic breech birth workshop with Shawn Walker in Toronto

The Association of Ontario Midwives is sponsoring a physiological breech birth workshop with Shawn Walker on Sep 11 & 12 in Toronto. Participants can attend a 1- or 2-day session.


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Tuesday, August 08, 2017

Please participate in the "Birth On My Terms" project

From the Birth On My Terms Project at Texas A&M University:
Were you coerced, forced or pressured to have a procedure(s) during labor and birth? Such procedures may include: epidural, episiotomy, induction of labor, augmentation of contractions, IV medication or fluids, cesarean section, Pitocin, antibiotics or other medications, electronic monitoring, movement or lack of movement, or pushing position.

If so, we would be interested in learning about your experience.

We are conducting a study that examines the experiences of women who have been forced or coerced to have a procedure, including cesarean sections, during labor or birth. If you have had such an experience and are willing to share your experience, please click on the link at the bottom of this post. You will be directed to our secure and confidential survey site. The survey will include questions about you, your reproductive history and questions about the pregnancy, labor, and birth that involved a forced or coerced procedure(s). Participants will also be asked about any consequences of having the forced or coerced procedure. Completion of the survey is expected to take about 30 minutes. Participants names will not be used in any publication of results. To access the Spanish version of this survey, follow the link bellow and select the language option in the top right corner.
For more information, contact:
Theresa Morris, Associate Professor of Sociology
(979) 862-3193
BirthOnMyTerms@gmail.com
www.facebook.com/BirthOnMyTerms
http://sociology.tamu.edu/morris-theresa/

IRB NUMBER: IRB2016-0084D
IRB EXPIRATION DATE: 12/01/2017.

Survey Link: https://tamu.qualtrics.com/jfe/form/SV_0HeWuF8x3FLKX41

**Feel free to share with those you feel would like to participate**


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Saturday, July 22, 2017

Cabin fun & misadventures with tires

We came home from France last Thursday night and left the next morning for a 9-hour drive up to my parent's cabin.

We blew one tire on the way up to our parent's cabin (turning the drive into a 12-hour trip), and another tire on the way home today. We are now experts in putting on the spare tire and hobbling to the nearest auto center.

Despite these misadventures our week in northern Wisconsin was fantastic.

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Sunday, July 09, 2017

How do medical information and patient preferences affect how a breech baby is born?

I just finished translating an excerpt from a French article that examines the interplay of medical information and patient choice in breech presentation. The authors include eloquent observations on how giving one-sided information to patients about the risks of vaginal breech birth, but not the risks of cesarean section, is "disinformation." They note that vaginal breech birth might face extinction in France, not for medical reasons, but because social pressures have heavily influenced obstetricians' fears and patients' preferences.

Original article: J Delotte, C Schumacker-Blay, A Bafghi, P Lehmann, A Bongain. Medical information and patients’ choices: Influences on term singleton breech deliveries. Gynécologie Obstétrique & Fertilité 35 (2007) 747–750. 

Excerpt from pp. 748-750 translated by Rixa Freeze, PhD, 2017. PDF version of the translation here.
Email me
if you'd like to read the original article and see their illustrations.


Discussion
Studies debating the preferred mode of birth for breech presentation highlight the value of studying and learning obstetric maneuvers [6]. Medical information and patient preferences are both important criteria in influencing how women give birth to their breech babies. The type of medical information given to patients is crucial because it reflects obstetricians’ current fears. Moreover, the nature and bias of the information provided during consultations influences patients’ choices. Patients' preferences are also derived from their own knowledge, their interpretation of information provided by their provider, and the influence of their close associates and therefore of society as a whole.

We first analyzed written information that specifically mentions risks related to vaginal breech birth. Indeed, the very act of including information about a potential complication in a patient’s file shows that the provider has overtly presented and emphasized certain risks. Written information included in patients’ files indirectly represents providers’ attitudes towards vaginal breech birth and how they likely discuss it in person with their patients. If, during a medical discussion, providers emphasize certain complications, they can influence patients’ choices. Although our study does not reflect the totality of information given to patients about breech presentation, it nevertheless provides a good approximation of providers’ overall attitudes during consultations. There has been an almost constant increase in giving patients this type of information (Figure 1). In 1996, no additional specific information relating to the risks of vaginal breech birth was noted in patient files. In 2005, this information was found in almost 70% of files.

The value of this additional written information is debatable. Doctors have an ethical obligation to give their patients clear, unbiased, and honest information, and their care must be evidence-based. Thus, exclusively presenting the complications of vaginal breech birth without presenting the complications of cesarean section clearly shows how current controversies over mode of birth for breech presentation are influencing the type of information given to the patients. This one-way information is likely not fair or unbiased. This type of information is, in effect, disinformation, since patients only learn about the risks of vaginal breech birth but not about the risks of cesarean. Patients’ choices can therefore be influenced by providers who give their patients written materials to protect themselves from medico-legal risks linked to the duty of informed consent. A possible solution may lie in standardizing the information provided to the patient and in presenting the risks of both planned vaginal breech birth and cesarean in a fair and honest manner [7,8]. Creating such a document is difficult and must take into account different varieties of obstetric practice. While documents on the modalities and complications of cesarean section have been produced by obstetrical societies, there is no such document concerning breech presentation. Until the French College Gynecologists and Obstetricians (CNGOF) produces a patient information sheet, patient information is currently based solely on what each individual provider or institution provides.

The second criterion that we analyzed, maternal choice, is probably influenced by providers but also by the beliefs of the patient or those around her. The rate of maternal demand for cesarean section for a term breech presentation was less than 10% until 2000, the year the Term Breech Trial was published. Since then, planned cesarean section solely for maternal choice has steadily increased to 25% today. In contrast, demand for cesarean section upon hospital admission, in patients who had previously consented to a vaginal breech birth during a consultation, increased at a slower rate. Nevertheless, this still occurs in nearly 15% of cases. This rate is particularly alarming since a cesarean performed during labor leads to increased maternofetal morbidity compared to planned caesarean section. Thus, if we consider the total population of women admitted to hospitals with a term breech presentation, about 30% of cases end in cesarean section due to maternal choice. This figure has tripled in the space of six years.

So does the debate on breech affect medical information, or does the exposure of this debate in the media influence patient choice? It is probably a combination of these two phenomena, since comparing the curve concerning maternal choice with written information about vaginal breech birth shows similarities—in particular, a very significant increase in their respective rates beginning in the 2000s to a stagnation at the present time.

Maternal choice, which is increasing in importance, has a strong influence on the debate over mode of delivery for breech. Indeed, to maximize reduction of maternofetal risks during vaginal breech birth, providers need to adequate experience and training during residency [9]. Current maternal choices are leading to a decreased rate of vaginal breech birth. This trend also leads to a decrease in the practice and teaching of maneuvers for vaginal breech birth. If maternal choices continue to evolve over the next few years, the practice of vaginal breech birth may no longer be taught in hospitals. In the absence of a rapid change favoring vaginal breech birth, the choice of delivery route for a term breech presentation may disappear, not for medical reasons but because of a societal debate that has influenced obstetric practice.

Conclusion
Breech delivery involves 3% of term pregnancies. Medical information and patients’ perceptions strongly influence providers’ abilities to learn and practice maneuvers for vaginal breech birth. This trend threatens the future of vaginal breech birth in France.


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Friday, July 07, 2017

Last day of school

Last day of school in France...lots of tears this afternoon.

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Tuesday, July 04, 2017

A life event of enormous magnitude

Here's a little gem I just unearthed from a 2004 article about vaginal breech birth in a tertiary hospital in Trinidad. In the conclusion, the authors write:


That last sentence...yes.
The individual woman's wishes must be taken into consideration as for some, labour is an integral and treasured experience and a vaginal delivery is a life event of enormous magnitude.


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Tuesday, June 27, 2017

Puget-Théniers

Two Sundays ago we visited a friend in Puget-Théniers, a little mountain village an hour away. Dio puked on the way up and Ivy almost did, but a piece of chewing gum saved the day.

We went on a post-lunch stroll and ended up taking an impromptu swim in a mountain stream. Clothing optional. My artist friend took the pictures.












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Friday, June 23, 2017

Articles on informed consent, autonomy, and forced/coerced interventions

I have discovered several recent articles about autonomy, informed consent, and forced/coerced interventions during childbirth that I highly recommend:

Also some older articles that are still relevant and useful:
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Thursday, June 22, 2017

The Vermelin method of vaginal breech birth

While translating this French article about nonfrank breech birth, I came across a reference to the "Vermelin method" of breech delivery. The author referred to Vermelin as if it were common knowledge--and it is, apparently, in the French obstetrical tradition. I found three theses from French-speaking midwifery or medical students that explained the Vermelin method.

In 2010, Jennifer Thomé wrote a thesis (PDF) as part of her midwifery degree from the Ecole des Sage-Femmes de Bourg en Bresse. She wrote:
Vermelin's non-interventionist method
Expulsion then takes place through uterine contractions and maternal expulsive efforts.

The operator attends the physiological delivery as described above and plays the role of "attentive observer," ensuring that dystocia does not occur. See appendices I and II.

A hard surface is placed under the perineum to receive the fetus.

The practitioner can pull down a loop of cord as soon as the abdomen has emerged and perform a Bracht maneuver to assist the expulsion of the fetal head, preceded or not by a Lovset maneuver (Lansac 2006). (p. 13-14)

France takes part in the approach of not using any systematic prophylactic maneuvers but instead resorts to them in cases of dystocia (DuBois 1990). For Bracht in 1938, "the number and the precocity of interventions" during the birth of the breech was the cause of the high fetal mortality rate; he therefore advocated abstention from maneuvers and promoted spontaneous emergence of the fetus for as long as possible. In 1948, continuing Bracht's advocacy, professors Vermelin and Ribon of Nancy also advocated spontaneous breech birth, showing that childbirth can take place entirely spontaneously; the hands-off "Vermelin method" was fairly widely adopted. (p. 17)

Appendix I: Spontaneous birth of the frank breech. 

Appendix II: Spontaneous birth of the nonfrank breech
Both illustrations are from Lansac J, Body G, Perrotin F, Marret H. 
Pratique de l'accouchement, 3ème éd éditions Masson, mai 2001.

In 2011, Marie Moncollin of the University Henri Poincaré in Nancy wrote a thesis (PDF) for her MD degree. She largely echoed the same points in Thomé's thesis.
At the beginning of the 20th century, most authors considered the breech presentation to necessitate obstetric intervention: prophylactic lowering of the foot, full extraction or release of the arms as promoted by Lovset in 1937. In 1938, Bracht reacted to this attitude and advocated abstention until expulsion. He then presented his maneuver for freeing the head, which we shall discuss later.

In 1948, the authors Vermelin and Ribon of Nancy defended an even more absolute abstention from obstetrical maneuvers. For Professor Vermelin it was important not to see pathology where it did not exist. While breech delivery was considered abnormal, even obstructed, at the time, Professor Vermelin wanted to show that a breech delivery could unfold in its entirety without intervening at all. He demonstrated that Mauriceau's maneuver, apparently innocuous, could be the starting point of cerebro-meningeal lesions, neonatal death factors, or psychomotor sequelae, and that it was better to do without the maneuvers. Thus Vermelin's technique of spontaneous delivery of the breech remains a classic for obstetricians of the Ecole de Nancy (see Vermelin 1956). (p. 28)

We have seen that the School of Nancy was marked by the Vermelin technique for the birth of the breech (he was a professor at the Maternité de Nancy from 1943 to 1961), but what about 50 years later? (p. 67)
Moncollin notes that French obstetricians today are not as hands-off as Vermelin advocated for; they generally assist with the birth of the arms and the head:
The birth of the breech according to Vermelin (1948) consisted of complete abstention from maneuvers. Thus, no maneuvers were practiced. However, to prevent asphyxia in the fetus, it is now advisable to finish the delivery, when the point of the shoulder blades appears in the vulva, by releasing the arms that are in the vagina and then the head. The Lovset (1937) maneuver will facilitate the expulsion of the shoulders, then the Bracht (1938) or Mauriceau (1668) maneuvers will free the fetal head. (p. 53)
She also makes this comment about breech birth at home:
Home birth:
Do not touch the breech presentation if obstetric maneuvers are not perfectly known. In this case, it is advisable to adopt the Vermelin maneuver. (p. 66)

Finally, a 2015 MD thesis by Daouda Aliou Kone (PDF) repeats the same information about Vermelin found in the other two theses.


References:
  • Dubois J, Grall J-Y. Histoire contemporaine de l’accouchement par le siège. Rev. Fr. Gynecol. Obstet, 1990; 85(5): 336-341.
  • Kone DA. Etude épidémio-clinique et pronostique des accouchements par le siège dans le centre de santé de référence de la communie II du district de Bamako. Thèse pour le Docteur en Médicine. Université des sciences, des techniques et des technologies de Bamako. Faculté de médecine et d’odonto-stomatologie. 6 Jan 2015.
  • Lansac J, Marret H, Oury J-F. Pratique de l'accouchement, 4ème édition, Paris, Masson 2006 553p: pp 125.
  • Moncollin MM. Choix de la voie d’accouchement en cas de présentation du siège: évaluation des pratiques cliniques à la Maternité Régionale de Nancy en 2008. Thèse pour le Docteur en Médecine. Université Henri Poincaré, Faculté de Médecine de Nancy. 11 Oct 2011.
  • Thomé J. La présentation du siège unique à terme: enquête sur les politiques de prise en charge des maternités du réseau AURORE. Université Claude Bernard Lyon 1, Faculté de Médecine Rockefeller, École de Sages-femmes de Bourg en Bresse. 2010.
  • Vermelin H, Ribon M, Facq J. Présentation du siège complet avec déflexion primitive de la tête; dégagement spontané en occipito-postérieure. Gynecol. Obstet. 1948; 47: 1250-1253.
  • Vermelin H. [The teaching and practice of the gynecology and obstetrics specialty] [Article in Spanish]. Tokoginecol Pract. 1956 Oct 15 (145): 569-81.

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Monday, June 12, 2017

A car birth, a bus birth, a yurt birth, an en caul birth, and a mother-supported birth

This reminds me of a Dr. Seuss book...
I can give birth in a car
I can give birth in a bus
in a yurt
with the caul
with my mom
A car birth
An Australian family pulls over onto the side of the road and has their baby in front of an apple shop.


A bus birth


A yurt birth
Through June 18, you can have your baby in this fully-equipped yurt in the middle of the Amsterdamse Bos. No charge to use the yurt. Sponsored by Birth Project: Look Again, which is hosting a number of activities in June. More information here.


An en caul water birth
The father lifts the caul off his daughter's face after she is born. Watch the video and read the birth story.


A mother-supported birth
A mother supports her daughter having her second home birth




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Sunday, June 11, 2017

Urgent--I need a Hamilton-style pregnant silhouette

Dear pregnant readers--I need your help! I need a photo of you, with your gorgeous pregnant belly, posing like Alexander Hamilton. Posed just like this, or as close as you can get and still clearly show off your belly.


Tight-fitting clothing is best. Bonus points if you are wearing tall leather boots!

I need a head-to-toe shot. Doesn't matter what's in the background as long as it's easy to distinguish between you and everything else (I will be turning it into a black-and-white silhouette).

To be used for an awesome project TBA.
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Wednesday, June 07, 2017

Breech and the art of obstetrics

Sometimes doing research is really, really boring. Other times I come across gems like this 1961 Lancet article titled "Management of Breech Presentation" by Leonard Lang. His humor and colorful language bring his words alive, contrasting with the dusty pages they now live on.

Also worth reading is his commentary on the last page about the trend towards increased cesarean for breeches.

The old masters in obstetrics of one or two generations ago—the mean who taught many of us—had a great deal of respect for the breech. Each of them had special technics and pet maneuvers that worked well in his particular hands. Each warned against certain dangers and pitfalls that should be anticipated, carefully searched for, and then properly handled, sometimes in rigid mechanical sequence. Many of these dedicated teachers had slogans and bits of advice that clearly expressed their concern. Dr. Williams often said that he could tell a really good obstetrician by the manner in which he conducted a breech delivery. Our old teacher, Dr. J. C. Litzenberg, liked to say that “any physician who said that he wasn’t afraid of a breech or never had trouble with a breech was either someone who didn’t do any work in obstetrics or was an ‘outright’ liar, and he could choose his own category!” Another exhorted the medical student to always be friendly with his competitor across the street, “because you may need him to help you with a breech some time!” They were acutely aware of the dangers inherent in breech delivery. They had to be. They had to depend upon their hands and keen mechanical sense which experience developed into a type of intuitive perception and manipulation that DeLee liked to call the “art of obstetrics.” They couldn’t readily resort to cesarean section once delivery from below was chosen. They didn’t have blood banks, antibiotics, and highly trained anesthesiologists.

No doubt our old teachers are turning in their graves as they contemplate upon the number of cesarean sections we are doing for breech today. We can only hope that St. Peter has tried to explain why things have changed. That might help a little but I’m sure that it wouldn’t completely satisfy that fine group of “Old-Timers.”
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Monday, June 05, 2017

A breech conference, 60 years ago

On November 22, 1957, the Obstetrics & Gynaecology section of the Royal Society of Medicine held a conference on breech. Conference notes were published in the March 1958 edition of the Proceedings of the Royal Society of Medicine (PDF).


It is a fascinating read. As I have been finishing conference summaries from the 2017 Sheffield breech conference, I reflected on how similar these two conferences were in spirit, although miles apart in content. I found the same collegiality, curiosity, and desire to improve outcomes. However, many of the practices seem quite out-of-date now. (Which makes me wonder: 60 years from now, what innovations discussed in Sheffield will have stood the test of time?)

I also noticed a marked gender shift in conference presenters, from exclusively male in 1958 to majority female in 2017 (with the 2017 audience predominantly female).

Here's a breakdown of speakers & topics and a "summary of the summaries," if you will. I would definitely read the originals, so I hope my brief teasers are enough to get you interested.

Dr. G. F. Abercrombie (London): The Timing of External Version. He advocates early external version beginning around the 30-32 weeks. Reports on his personal series of ECVs.

Mr. John Hamilton (Liverpool): Discusses the Burns-Marshall technique developed in and used by the Liverpool Maternity Hospital. General advice on selection criteria and labor management. A pithy statement about breech birth at home: "I will say at the outset that there is only one place for breech delivery, whether multigravida or primigravida, and that it in hospital." (Remember, at this time in England and Wales, around 33% of births still took place at home. See the UK Office of National Statstics report on home births.)

Mr. J. H. Peel (London): Makes an argument for ECV to lower the rate of breech deliveries and thus the overall mortality rate due to breech. Advocates for ECV around 34 weeks. Reports on both a personal series and a hospital series.

Mr. David Methuen (Oxford): Presents a series of 448 breech deliveries from his department in Oxford between 1952-1956. Advocates for using pudendal block or epidural anesthesia rather than general anesthesia for breech deliveries.

Mr. C. K. Vartan: Advocates for inducing all breeches at 38 weeks to produce "smaller babies which would not need to be extracted." A brief discussion of FHR after the baby is born to the shoulders.

Mr. Gilbert Dalley: Prefers ECV to breech delivery. Presented a 10-year series of births at West Hill Hospital in Dartford, both vaginal breech births and ECVs. Advocates performing ECV before the 35th week.

Mr. J. S. Hesketh: Concerned about the amount of traction described by Mr. Hamilton in the Burns-Marshall technique.

Mr. Wilfrid G. Mills: We should distinguish between extended (frank) and flexed (complete/incomplete/footling?) breech. Strong advocate of ECV, although he thinks it should be performed whenever the breech presentation is diagnosed, rather than at a set time. Gives an alternate explanation for why intracranial hemorrhage occurs in some breech deliveries.

Dr. J. Vincent O'Sullivan: Supports Mr. Peel's plea to do ECVs and suggests between 30-34 weeks. Discusses a different technique for delivering the aftercoming head by "rolling" the head over the perineum and pressing the nape of the neck close against the symphysis.

Mr. John Hamilton then replied to some of the earlier comments.



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Thursday, June 01, 2017

Obstetric Blinders: Cord Clamping

In my last post on obstetric blinders, I quoted a 1970 article that discussed upright birth among the Bantu and Polynesian people. That article quoted M.C Botha's 1968 article on the management of the umbilical cord in labor from the South African Medical Journal. (Full text here.)

I managed to track it down and was blown away by what I found--both by the evidence against cord clamping and by the obstetric blinders that Botha wore.

Botha's article begins with some quaint observations about childbirth in the Bible and other ancient literature. Botha then examines "primitive" birthing practices:
The most primitive of the Bantu people believe that it is completely wrong to touch the cord until the whole placenta is expelled. Once bearing-down pains commence, the parturient woman sits on her haunches, as if in defaecation. The trunk is bent forward, thus increasing the intra-abdominal pressure. Her bearing-down efforts are not new to her, since she has repeated the same act in defaecation daily since she was born.

Once the baby is born, the woman (Fig. 1) will remain in a squatting position watching her new baby. The placenta delivers itself from the vagina without any maternal effort (Figs. 2 and 3). Once the placenta is delivered, by gravity, the membranes usually remain in the vagina. The patient then lifts herself on her haunches and the membranes fall out. Only now does she pay attention to the cord (Fig. 4).

Hooten [1 sic] reported the same observations. Vardi [2], on account of this observation by Hooten, investigated the extra amount of blood that can be transfused into the baby by gravity; the residual blood in the placenta was approximately 11.2 ml. By bleeding the cord the total average blood volume was 100 ml. They thus concluded that by gravity, and not clamping the cord, the baby gets an extra 89 ml. of blood. This is exactly what happens in the Bantu baby.

Working among the Bantu for 10 years, attending 26,000 Bantu and seeing only abnormal cases, I found many other complications, but a retained placenta was seldom seen. If called to a case, I usually found that the terminal part only of the membranes was still in the vagina, and had merely to be lifted out. Blood transfusion for a postpartum haemorrhage was never necessary.

It gets more interesting. In the next paragraph, Bantu writes:
In accordance with this observation, the third stage of labour in White patients was managed with the use of Syntometrine [Pitocin], letting the cord bleed, and the Brandt-Andrews manoeuvre, and in 800 cases over the past 10 years no retained placenta or postpartum haemorrhage needing blood transfusion has been found. 
Note the difference in care between Bantu women (cord left intact) and White women (oxytocics, managed 3rd stage, cord clamped on the baby's side and left to bleed on the maternal side). Bantu babies also received an "extra" 90 ml of blood compared to White babies.

Let's see what else this article has to offer. I'm going to skip the next section on the history of cord clamping from the 16th century to the present. It's worth reading on your own, however.

Next, Botha discusses a study he conducted on a consecutive series of 60 unselected women, 30 with clamped cords and 30 intact cords. In both groups, "the uterus was not handled after the birth of the baby. The placenta was not handled until the mother felt the urge to bear down herself and was only received when it appeared outside the vagina. No oxytocic drugs were used." Women with intact cords birthed their placentas much more quickly and with much lower blood loss, compared to women whose cords were clamped.

Botha did another study in which he injected dye into the placenta immediately postpartum via the umbilical vein and took a series of X-rays to visualize the descent and birth of the placenta. He found that placentas with unclamped cords delivered more quickly than placentas with clamped cords.

Let's go to the end of the article, now, in which Botha discusses his findings. He begins with an unsurprising observation: "In the cases where the cord was not clamped in the third stage there was a statistically significant difference in duration and blood loss compared with those where the cord remained clamped."

Further down, he notes that an upright maternal position helps the placenta birth rapidly and with little resistance:
As there is fundal dominance in uterine activity, the placenta is forced in the direction of least resistance towards the lower segment and vagina. If the cord is bled, this process is so rapid that retraction has not yet taken place in the cervix, and the placenta, reduced in size, is expelled without resistance into the vagina. If the patient is sitting on her haunches, it will fall out by gravity.
Skipping ahead a bit more:
If the cord is clamped, counter-resistance from the placenta may be so great that retraction may come to an end. The placenta will then be separated by retroplacental blood, which, in my opinion, is not normal but abnormal. this takes place slowly and by the time the placenta is separated the cervical muscle has also retracted. The placenta is bulky, due to the blood it contains, and expulsion is difficult. If expulsion is not possible, the inevitable result is that in a certain percentage of cases the placenta will be retained, with associated postpartum hemorrhage.
Botha notes several times that the baby receives an "extra" 90 ml of blood if the cord is left intact. (I suggest phrasing it in the inverse: when the cord is clamped, the baby loses 90 ml of blood.) His next paragraph again mentions the difference in blood received by the baby:
If the cord is not clamped until the placenta is expelled, the baby will receive an extra amount of blood, which is approximately 90 ml., as reported by Vardi. 
He also notes that Rh- sensitization is rare when the cord is left intact and the placenta is birthed spontaneously.

The conclusion is fascinating--and disturbing--in how firmly Botha's obstetric blinders were in place. I had expected his conclusion would recommend leaving the umbilical cord intact until the placenta is birthed. This would both reduce both retained placenta and postpartum hemorrhage and give the baby its full blood volume. But instead, Botha recommends a surprisingly complicated method of third stage management:


Ironically, midwives would be giving superior care by simply leaving the cord intact and waiting for the birth of the placenta, because the baby would also retain 90 ml of blood in the process.

This is a classic example of how "modern" obstetrics pursues an invasive and complex solution (oxytocic drugs, bleeding the placenta, removing the placenta with controlled traction and pressure on the uterus) while discarding the simpler, better solution (leaving the cord intact and waiting for the placenta to birth on it own)--even though the "primitive" solution is easier for the attendant and better for the baby. 

References
  1. Hooton, Earnest A. Man's Poor Relations. 1st ed. New York: Doubleday, 1942. p. 412. (Corrected from the original)
  2. Várdi, P.: Placental transfusion: an attempt at physiological delivery. Lancet 2:12–13, 1965.
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Julia & Harry: Having our breech babies in Sheffield

Julia & Harry
A parent's view: Having our breech babies in Sheffield
North of England Breech Conference, Sheffield
Day 2

We had a lovely family talk about their two breech births: Julia & Harry. Julia first talked about the birth of Frank, her oldest, who is now 2 1/2. They had been trying to get pregnant for around 4 years and finally succeeded with AIUI. The whole process was very involved medically, with lots of scans and visits, and emotionally stressful.

They found out Frank was breech around 28 weeks, but initially Julia's providers told her not to worry, he might turn. Julia tried all sorts of natural techniques to encourage him to turn: moxabustion, acupuncture, inversions, swimming upside down, etc. Her providers booked her in for a cesarean, and at that point Julia's whole world crumbled. She hadn't realized how much emotional stress she was carrying. That last straw—to say we’re going to just come in and take your baby out—made her feel powerless, like there wasn’t anything she could do. Her whole life she had looked forward to giving birth. It was a very primal thing. And being told that she was going to have a cesarean really upset her.

Harry: If someone tells you you can’t do something, you generally want to do it.

Julia: Julia told her midwife  that she wasn’t happy about the cesarean. She had wanted a home birth. Her midwife said, you know, there’s a team who can do breeches! She got referred to Helen Dresner Barnes and felt so relieved that she’d have a chance to try. She did lots of reading and research and read other birth stories. Julia had a cesarean booked in, so she had a bit of deadline, but at least she had a deadline and some options. Julia went into labor naturally and was in a good head space: if I needed a cesarean, it would be fine. In the end, she had her baby vaginally in the hospital. Although the whole process of pregnancy was quite hands-on, the actual delivery day was very hands-off, with no intervention by the midwives. All three of them just let her do her thing to get him out.

Two years later, they weren’t actively trying to get pregnant, and Julia wasn’t having any periods. The doctor said she’d need to go through AIUI again to get pregnant. Julia went in a week later for a bloated belly and discovered that she was 4 moths pregnant! With the second pregnancy, the midwives were more hands-off. Julia had just one scan at 16-17 weeks.

Harry: Such an opposite experience form the first pregnancy.

Julia: Julia went into labor planning a home birth and thinking her baby was head-down. Florence came within 2 hours of labors tarting. Julia had the same team of midwives, who liked to care for “repeat offenders.” She had Florence on her own. Sally, one of the midwives, arrived 10 minutes later.

Her two pregnancies were very very different experiences, from high intervention the first time and pretty much nothing the second time. Julia doesn't think the second time would have gone the way it did—the trust in herself, in her own instincts—without the first experience and having had the team there the first time.

The main thing Julia learned from her two breech experiences: "I wanted the power myself to be able to make an informed decision on what I was to do, whether it was to have a cesarean or not. You can only trust yourself if you have the support in order to feel you can trust yourself."

Harry: In hindsight with Frank, we were engaged with medical science and technology at every point. I was amazed at how instinct kicked in when labor started. And the breech team gave that space, that light touch, to let it kick in. That was the most surprising and, in hindsight, the most obvious thing I realized after Frank.

Julia: If we had known Florence was breech before she was born, there might have been more intervention.

Helen Dresner Barnes: I learned that Julia had a breech birth when I came into her home. Julia told me, “It was okay; I recognized what was happening. I don’t know what I would have done if the baby was head first!”
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Monday, May 29, 2017

Anke Reitter: Upright breech skills & recognizing and managing breech complications

Anke Reitter
Upright Breech Skills & Recognizing and Managing Breech Complications
North of England Breech Conference, Sheffield
Day 2

Dr. Anke Reitter is a Maternal-Fetal Medicine specialist and a Fellow of the Royal College of Obstetricians and Gynaecologists. She currently directs the maternity department at the Sachsenhausen Hospital in Frankfurt. She specializes in breech, multiple pregnancies, high-risk pregnancies, and ultrasound--and is also an IBCLC!

I would also recommend reading Anke's presentation about upright breech maneuvers from the 2016 Amsterdam Breech Conference. I omitted repeated material in this summary. Shawn Walker's posts about nuchal arms are also very helpful.

After seeing Gail Tully's presentation, Anke mentioned that she was very inspired--as usual! Her talk fit very well into Gail’s regarding how the levels of the pelvis require different actions.

Anke showed a video of a mother who had had a previous cesarean after an attempted vaginal breech birth; the cesarean happened at full dilation due to abnormal fetal heart tones. Her next baby was also breech, and the mother was very motivated to have a vaginal birth. The baby was born to its torso and the arms came out, but the body remained slightly oblique. Anke noted that the head was tipped back and sideways. The solution: helping bring the head back into the midline. After that, they were able to flex the head. This birth was a classic example of when to help in a vaginal breech birth.

She and Andrew Bisits have created a flowchart showing normal (green) and abnormal (red).

"Hands-off" if progress
"Hands-on" if delay

Rixa's note: This flowchart would go together well with Gail Tully's presentation and her Breech Birth Quick Guide. I have retyped the chart since it didn't show up well on the photos I took.


For Anke, rumping--meaning the bitrochanteric diameter is born--is the point of no return. A baby that has rumped has to be delivered vaginally. She asked the audience: do you all agree on this definition?

From Anke's time in Bergen, Norway, she learned everyone there does Løvset for breeches. They don’t know other maneuvers; they "really love Løvset." The key message is to grab something with a bony structure to protect the baby's internal organs, either the pelvic girdle (mother on back) or the shoulder girdle (mother on hands & knees).

Anke remarked that in Sydney, where Dr. Andrew Bisits works, most of the babies have no problems with the arms. She wonders whether we have maybe started to interfere too early? She turned to ask him, "Andrew, why do you have so few situations when the arms/shoulders are held up?"

Andrew: When we are using the birth stool with the possibility of going to H&K, the arms sometimes might be a bit extended, but they’re always low enough to release easily. I’ve never encountered anything as difficult as that.

In real life, if there is a nuchal arm, the body often is not entirely out and you have to go inside the mother to get to the shoulders.

Elevate and Rotate: When you turn a baby with the shoulder grip, don’t pull down. You might even want to push the baby up just a bit, and then turn it. Turn in the direction the baby’s arm is pointing. She often feels some resistance as the baby’s nuchal arm is just starting to slip past the head. Overcome that resistance, but remember: no traction. Turn a full 180, then 90 back. The baby should end facing the mother's anus.

From Louwen et al
Once the bitrochanteric diameter is out, you should have the whole baby out within 3-5 minutes.

Betty-Anne Daviss: There's been back and forth about whether you should be leaning forward on the bed. If you get a mother up on the birth stool, it often fills the hollow of the sacrum and the baby comes right down. When we watch these videos of mothers doing prayer positions, that’s the opposite of getting mothers upright on the stool. I’m trying to reconcile that.

Jane Evans: Regarding Andrew’s comment: maybe leaning too far forward encourages the anterior arm to be caught.

Gail Tully: Yes, you’re closing the brim if you lean over.

Time is an issue. After you release the arms, you still need to be aware of what’s happening. Don’t wait 1-2-3-4-5 minutes after the arms are born, even if the other signs are good. Be proactive, especially if you have less experience.

Gail: Yes, because you don’t know what you are going to run into next.

Shawn Walker: With women who have high BMIs, sometimes we need to lift the buttocks up. This releases the soft tissues to help the head release. It’s a soft tissue dystocia.

Anke noted that providers have learning curves as they are adapting to doing breeches on hands and knees. She showed a video of an American OB doing a H&K breech. This OB was hands-on several times when the signs did not warrant an intervention. The audience was visibly wincing and groaning at several points.

After we saw the video, Anke made an important point--this video shows us that learning is a good thing. If we do these trainings and if we start talking about upright breech, we need to really understand the things we learn in these conferences. If you offer a study day, it needs to make an impact in the right direction. This OB had the best intentions and it's great that she offers women the choice of a VBB. The birth would have been spontaneous if she hadn’t touched the baby. But there’s a learning curve at the beginning for providers. Anke herself  had a learning curve.

Shawn: In this video, we need to exercise compassionate understanding that there’s this learning curve. Don’t attack and be judgmental. We all change and adapt as providers. We need to understand providers’ learning curves so we can teach more effectively.

Jane: It’s really difficult for some people to turn things over when they are used to seeing women on their backs. Most people understand if I talk about following the curve of the sacrum. It’s easier to follow the sacral curve if you do the birth "upside-down" (having the woman upright or hands and knees).

Anke mentioned a few indirect maneuvers to help free the head:
1. Gluteal lift: It can release enough soft tissue to help a non-nuchal arm come out.
2. Maternal pelvic shift (push mother’s entire pelvis forward): This will help deliver the head according to the pelvic curve.
3. Controlled head delivery using the shoulder press (Frank's nudge) and modified MSV

Why still offer vaginal breech delivery?
Around 30% of breeches are still undiagnosed when labor begins. All maternity units must be able to provide skilled supervision for vaginal breech birth where a woman is admitted in advanced labor. Protocols for this eventuality should be developed.

A woman should be referred to a center if her own unit cannot provide the service. Centralization is the best strategy to ensure the most experienced team involved. You need a 24/7 "breech squad."

Vaginal breech birth prevents the first cesarean and thus a scarred uterus. Offering vaginal breech birth is an important factor in reducing the cesarean rate among primips. VBB can also help lower the repeat cesarean rate. This is important at both an individual and population level.

Finally, cesareans have a major impact on the life span of women in developing countries. (Rixa's note: as an example, see Dr. Thomas van den Akker's presentation Who pays the price? from the 2016 Amsterdam Breech Conference.)

Reviewed by Anke Reitter, May 29, 2017
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Panel discussion on breech, part II

Panel Discussion on Breech, Part II
North of England Breech Conference, Sheffield
Day 2

This was the final session of the North of England breech conference. Panel members included
Adorable breechling legs. Photo from the conference website.
Fetal monitoring 
Audience member: At Oxford and Sheffield, what do you do about monitoring?

Helen: We talk to women, we present the evidence, we listen to what they want. We’re mindful of what our colleagues want, but we’re women-led. It’s fair to say we do both--some women choose intermittent, some use continuous. We have wireless monitors, so they aren’t strapped down at all. Those monitors can’t get too wet, but since we don’t have water births for breech that's not too much of an issue.

Julia: If they have an obstetric risk factor (gestational diabetes, VBAC, meconium, etc.), we monitor them. A lot of our breech births come from women who had wanted a home birth, so continuous monitoring is not on their agenda.

Anita: We use wireless CFM. Women do go into the pool in the first stage. We ask women if they want the monitors off a bit, but the women generally say it doesn’t bother them. Continuous monitoring hasn’t been challenged yet, but we wouldn’t force it on a woman. I'm very comfortable with both intermittent and CTG, but the recommendation is continuous. We look at baseline and variability; we worry less about dips. In some ways, 15-minute intervals of intermittent monitoring are better/safer than continuous, because you're really focusing on the heart rate, not just having it on on the background.

Betty-Anne: In Ottawa, there’s a large iatrogenic factor of being in hospital. I'm a community midwife: half of my births are at home, the other half are breeches in hospital. I try to use the best of both worlds. I am required to keep up a certain number of home and hospital births because of my license. I bring breech women in hospital around 7-8 cms. If they go in hospital too early, they get interventions. I do want to do the births in hospital because most Canadian women don’t want to have their breech babies at home. I am willing to offer home breech birth, though, for women who really want it. My insurers are totally supportive of me right now because I've gone to them many times when there's been an iatrogenic problem. I have documented 38 cases involving breeches where I had to intervene in the hospital because either the doctor didn’t know what he was doing or he was going against guidelines. I have the insurance on my side now, even if the hospital staff is not. That’s why I am very careful to do continuous monitoring in my situation so I can cover myself.

Gail: As a home birth midwife, I am encouraging my community of colleagues to do more frequent monitoring especially in 2nd stage. I see more early separation of the placenta with breeches. When the placenta is detached a few contractions before the baby is out but gravity makes the baby look pink, that baby actually has an issue. It’s worthwhile to keep a closer eye on those babies, especially 2nd twins.

Helen: If there is nothing to do, don’t do it. If we just let a woman be a mammal, she’ll do it. We do talk to our women about following their bodies and being instinctive. Even making a suggestion can interfere. Do nothing unless we have to.

Audience member: We tend to listen in just to cover our asses!

Waterbirth and aromatherapy
Audience member: What about water therapy or aromatherapy during labor? How much do things disrupt physiology versus help it?

Jane: I don’t think I ever said that aromatherapy would have been disruptive. Laboring in water with a breech is absolutely fine. Sometimes women refuse to move and they have their babies in the pool. That has happened a couple of times to me. When the women stay leaning forward, the buoyancy of water keeps the baby from doing the tummy tuck. If the woman is on her back, buoyancy brings the baby the “right” way around the sacral curve. So supine immersion might be better than H&K in the water, for a breech baby. Cornelia Enning has moms birth standing up in a water barrel for breeches. She has the dad put his hand down in the water so the baby can “stand up” on his hand.

ECV and hypnosis
Audience member: There has been lots of talk about ECV, but I haven’t heard any mention about using hypnosis for ECV. In our unit we refer to hypnobirth team for their breeches and have a high success rate. Maybe that’s something that could be explored?

Helen: We have lots of hypnobirthing teachers in town, but it is not offered through the Trust. We do hypnosis for all women, generally.

Audience member: Do you have a specific script for turning breech?

Helen: No.

Betty-Anne: There are 2 studies on hypnosis and ECV. One showed benefits and the other showed no effects.

Closing remarks by Dr. Andrea Galimberti
I see lots of enthusiasm here. I see people who are trying to go back and create something where there was nothing before. When we look at our roles as health care providers, our primary responsibility is to look after women. We are also accountable to our professional bodies and to our place of work as employees. If we are thinking about making changes or creating new services, it’s important that we evaluate our responsibilities in respect to all 3 roles within the triangle: mothers, profession, and employer.

Choice seems to be the main word that we’ve heard these past two days. I’ve heard quite disturbing accounts of colleagues who are unable to offer the choice that they should.

We need to relate to our employers. We need to be prepared to open a dialogue so that the system we put into place for breech birth is acceptable. When adverse events happen, we want our breech service to continue and not just be shut down.

Maybe we’ll meet again in a few years? This reminds me of talking to women after labor. They say “never again!” But...a few years later...they are back again!

Disclaimer: I am working from typed notes, not from recordings. If something I have written is not accurate, please contact me so I can make the appropriate changes.
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