Wednesday, November 29, 2017

Can a breech baby be turned during labor?

When a woman has a singleton breech presentation at term, she is usually presented with one or more of the following three options:

  • Planned cesarean section (universally offered)
  • External cephalic version, usually at or after 37 weeks (sometimes offered)
  • Planned vaginal breech birth (rarely offered)

However, a fourth option exists: an external cephalic version during labor. While this is usually done on a breech 2nd twin after the 1st twin is born, it also works for singleton babies.

Image source 
Intrapartum external cephalic version (IP ECV) is strategy for avoiding both a cesarean and the risks of vaginal birth in a singleton breech presentation, especially for unfavorable presentations such as footling breech. Two articles report high success rates with IP ECV as long as the membranes are intact.

Kaneti et al (2000) analyzed a prospective series of in-labor ECVs for unengaged term footling breeches with intact membranes. Of 21 eligible women, 8 chose cesarean section and 13 chose IP ECV. 12/13 versions were successful and 10/12 women gave birth vaginally. Of the two failed vaginal births, one was for cord presentation and the other for arrest of labor. The babies were turned between 2-8 cm dilatation.

All women were multips; the physicians would have been willing to attempt IP ECV in primips as well, but never had the opportunity. The ECVs were done in the OR with Ritodrine and regional anesthesia when possible. The woman with an unsuccessful ECV went straight to cesarean while the twelve women with successfully turned babies received amniotomy and continued their labors in the labor ward. The one failed ECV was with a woman at 8 cm whose membranes ruptured at the beginning of the version. There was no maternal or neonatal morbidity, and all Apgars were 9 or 10.

Ferguson and Dyson (1985) report on a similar series of 15 women in labor with term breech presentations and intact membranes. Earlier in the study period, they had attempted IP ECV on women with ruptured membranes, but with no success. The authors do not specify type of breech presentation, other than that the women were not considered good candidates for vaginal breech birth. 6 were primips and 9 were multips.

They followed a similar protocol to Kaneti’s (versions were done in the OR under tocolysis between 1-8 cm dilation; successful versions were returned to the labor ward). 3/15 had epidural anesthesia during the version. 11/15 versions were successful (2/6 for primips, 9/9 for multips) and 10/11 women gave birth vaginally. The one failed vaginal birth was due to arrest of labor in a primip. Maternal and neonatal outcomes were good.
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Monday, November 20, 2017

Consent for a forced cesarean

This summer I was listening to Dr. Stu's Podcast while repainting the windows on my carriage house. (Whenever I listen to something memorable, I also distinctly remember the location where I was listening--does the same thing happen to you?) It was an episode about Consent for a forced cesarean.

In a blog post, Dr. Stu explains why he created a consent document for women being forced into having an unwanted cesarean section due to hospital policy banning breech, VBAC, or vaginal twins. The consent form is brilliant.



If all women being forced into unwanted cesareans asked their hospitals to sign this consent form before their surgery, hospital bans on vaginal birth for breech, twins, and VBACs might change overnight.

The consent form documents that the woman does not consent to the surgery, that ACOG's guidelines allow for vaginal birth in these situations and forbid the use of force or coercion, and that the hospital will be responsible for any complications due to the surgical birth, both short- and long-term.

Dr. Stu has invited everyone to download, edit, and distribute his consent form widely.

ps--I would suggest adding ACOG's 2016 Committee Opinion on Refusal of Medically Recommended Treatment During Pregnancy to the list of references.


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Sunday, November 19, 2017

Happy 11th Zari!

We had a relaxed birthday party this year. I didn't even try to do something as amazing as last year's outdoor obstacle course. This time we baked cupcakes and bought lots of toppings...and that was it! The kids played indoors, since it was raining the entire day. They slid down the stairs on a mattress, danced with a strobe light, and played hide & seek and sardines.



Zari's birth announcement and birth story
1st birthday
2nd birthday and 2 years old
3rd birthday
4th birthday and 4 years old
5th birthday
6th birthday
7th birthday
8th birthday
9th birthday
10th birthday
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Wednesday, November 08, 2017

Reflections on Russia

What an amazing week I just spent at the Life Birth Pelvis conference in St. Petersburg, Russia! It was challenging and overwhelming (in a good way). This is the 8th international conference that Katerina Perkhova has organized.

Some thoughts, in no particular order:

Breech knowledge doesn't always cross political or linguistic borders
I gave two presentations on breech birth: one on the history of maneuvers from 1609 to the present, the other on evidence on term breech since the Term Breech Trial. Everyone involved with breech birth in North/South America, Europe, Australia/New Zealand, and many parts of Africa and Asia is familiar with the Term Breech Trial. But not Russia! "What is this Term Breech Trial you are speaking of? We have never heard of it." I had to explain the background and significance of the TBT in order for my presentation to make sense.

Conversely, Russians were quite familiar with Tsovian, aka the Tsovyanov. I suspect they were surprised we didn't know about him! I have now discovered 15 obstetric journal articles about his methods in Russian, Czech, Hungarian, Polish, and--in one case--Spanish. I also found contemporary Czech textbooks that mention Tsovian (spelled Covjan--sneaky Czechs making it harder for me!) and a Dutch article examining whether Bracht's or Tsovian's methods came first.

I am so excited that I get to help breech knowledge cross political and linguistic boundaries! My wonderful translator Alesya is excited to translate the articles and book chapters I am working on. And perhaps some of my breech conference summaries...

Hot & Cold Water
I was puzzled at how hot and cold water were frequently suggested as remedies. Your newborn needs resuscitation? Use hot and cold water! Is your premature baby having a hard time nursing? Hot and cold water!

I didn't fully understand this concept until I did a full Russian sauna on the last night of the conference. This includes going naked into the sauna, being beaten with bunches of oak leaves (it feels heavenly, like the heat is being beaten deep into your body), and then plunging into an ice-cold pool of water. And then doing it again several times. After the fourth cycle, I got the biggest endorphin rush of my life--comparable to being in labor. You know the dizzy, buzzing, high feeling you get all over your body between contractions? That endorphin rush. It lasted for about 2 hours.

And then I got it. Hot and cold water as therapeutic? As a way to maximize health and well-being? Yes, for sure! I have a friend here in the States who is a Russian translator, and she says that Russians often use the expression "tempering the baby," as one would temper steel with repeated applications of heat and cold.

In Western (is that the right word?) obstetric practice, we're concerned about getting the baby warm and dry immediately. Allowing a baby to be cold and/or wet is absolutely verboten. Maybe we could learn something from the Russian use of hot and cold water.

Right brain, left brain
This was the most right-brained conference I have ever attended. We had one "normal" conference room with rows of chairs and a projection screen for Powerpoint slides. This is where I gave my two breech lectures, a talk on unassisted birth, and a session on newborn resuscitation with Sister Morningstar.


But our other conference room was a Red Tent room. The walls were draped with red fabrics, the chairs were replaced with bean bags, and candles and incense and altars took the place of projectors and pointers. The floors were covered with intricately embroidered fabrics. In the corners were private alcoves for doing yoni steams, draped on all sides with red fabric.





Days were partially left-brained, partially right-brained, but evenings and nights turned magical and mystical. Sometimes intimate and sacred, sometimes raw and brutally honest, but always healing. Having Sister Morningstar, a Cherokee midwife, to lead the evening sessions was an honor. I've been quite cynical about religion lately, and these five days were a reminder that women have tremendous spiritual power and that spirituality in its widest sense is so much grander than anything one religion can offer.






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Wednesday, November 01, 2017

Breech updates: Recent evidence on term breech & maneuvers for upright breech birth (Portland, Nov 12)

If you're in or near Portland, you might like to attend this event I am speaking at on Nov 12. Space is limited, so you must RSVP to reserve a spot. Details below.

~~~~~

Breech updates: 
Recent evidence on term breech & maneuvers for upright breech birth
Rixa Freeze, PhD

Sunday, November 12, 2017 from 4-6pm

Cost: Free (donations gladly accepted by Rixa to fund ongoing research)

Location: private home of Hermine Hayes in SW Portland, near Lewis and Clark College
(exact address will be provided to those who RSVP)

RSVP to: Jesica Dolin - jesicadolin@yahoo.com

This session will share information regarding the history of breech maneuvers from 1609 to the present. The presentation begins with a historical journey through obstetrical maneuvers for breech presentation. It documents every maneuver that has been uncovered by Rixa's research, tracking them back to their original inventors and dates, when possible. Next, she looks at current innovations in upright breech birth. The presentation tracks how knowledge about upright breech birth emerged and converged over the past several decades. Rixa will describe the key principles of upright breech birth and the physiological mechanisms of normal breech birth. She'll then review the maneuvers that have been invented to deal with stuck heads and arms when the mother is upright. The session will also cover the evidence on term breech since the 2000 Term Breech Trial.

Jesica Dolin, BSM, CPM
www.HiveCE.com


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