Friday, October 13, 2017

Michel Odent on breech

Whenever I pull Michel Odent's book Birth Reborn off the shelf, it feels like phoning a dear friend after a long absence. We catch up on life and I remember why I enjoy this person so much.

Michel Odent is a French surgeon and obstetrician who was in charge of the Pithiviers Maternity Unit for over 20 years. At a time when cesarean rates were rising and births in France were highly medicalized, Odent turned the maternity wing at his state hospital into a haven for undisturbed, physiological birth. Most of his changes were low-cost and low-tech: creating an environment in which women were private and completely undisturbed during labor. He replaced delivery tables with big, low mattresses and cushions, birth pools, and simple furniture to aid spontaneous movement. His maternity unit had a 6-7% cesarean rate during the 1970s and 80s, even though it accepted an unscreened population.

I just opened Birth Reborn after a good year or two and turned to a section on breech birth. In his words and photos (pages 103-105 in the 2nd edition):


Finally, within the realm of labor and birth, one quickly learns to expect the unexpected. Sometimes a woman will have a quick and easy labor when professionals believed only a cesarean was possible. For example, women who have previously had a cesarean are sometimes told that they will always give birth that way. Yet at our clinic, one out of two women who have previously had cesareans succeed in giving birth vaginally. Nor do breech deliveries always justify the operation, although this has, nevertheless, become almost the rule in many conventional hospitals. From our experience with breech babies, we have found that by observing the natural progression of first-stage labor, we will get the best indication of what to expect at the last moment. This means we do nothing that will interfere with first-stage labor: no Pitocin, no bathing in the pool, no mention of the word "breech." If all goes smoothly, we have reason to believe the second stage of labor will not pose any problems. Our only intervention will be to insist on the supported squatting position for delivery, since it is the most mechanically efficient. It reduces the likelihood of our having to pull the baby out and is the best way to minimize the delay between the delivery of the baby's umbilicus and the baby's head, which could result in the compression of the cord and deprive the infant of oxygen. We would never risk a breech delivery with the mother in a dorsal or semi-seated position.

If, on the other hand, contractions in the first-stage labor are painful and inefficient and dilation does not progress, we must quickly dispense with the idea of vaginal delivery. Otherwise we face the danger of a last-minute "point of no return" when, after the emergence of the baby's buttocks, it is too late to switch strategies and decide on a cesarean. However, although we always perform cesareans when first-stage labor is difficult and the situation is not improving, most breech births in our clinic do end up as vaginal deliveries.

Here is a brief video of a breech birth at Pithiviers. Notice that the baby does not rotate to sacrum-anterior after the trunk is born (the most likely culprit is a nuchal arm). Odent steps in right away and frees the arm. The baby is born very quickly.


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