Andrew Bisits: Intrapartum CTG monitoring in breech presentation

Andrew Bisits

Intrapartum CTG monitoring in breech presentation

North of England Breech Conference, Sheffield

Day 2

Andrew Bisits is the Director of Obstetrics at the Royal Hospital for Women, Sydney, Australia. His hospital sees over 4,000 births per year. Andrew is working on several initiatives to promote normal birth by establishing primary midwifery care for women and by attending vaginal breech births. He has also created a vaginal breech training course, Becoming a Breech Expert (BABE).

Today’s presentation examined the evidence for CTG monitoring in breech presentation. To what extent is there evidence? To what extent are doing it because it’s part of our comfort zone and what we’ve always done?

Andrew does not have firm answers, but finds this topic necessary and helpful to discuss. At this conference, people can think clearly and are invested in the issue. At home where he works, people are so busy and so fearful that they just react, they don’t think. Here at this conference, we’re sitting back and thinking, discussing, and trying to look at evidence in the broader context. There are so many pressures back at the workplace that you can’t think about these things.

He will ask two main questions about CTG monitoring:

• Do normal women with normal babies need it?
• Can CTG help make VBB as safe as cephalic vaginal birth?

There are small—perhaps significant—differences between cephalic and breech vaginal birth.

The question of CTG monitoring has to be viewed within the context of the various pressures on providers to intervene: We have this normal process, yet we continually feel pressure to intervene. Some of the pressure might come from evidence, but social pressures and a huge medico-legal industry exert the most pressure. Despite being in an evidence-based era, the pressure to intervene based on factors other than evidence—medico-legal cases, social pressures, various opinions—is huge and cannot be ignored.

Learning from adverse events:
What prompted Andrew to talk about this? He was party to a number of adverse events in New South Wales related to breech. By adverse events, he means neonatal mortality (NNM), perinatal mortality (PNM), or very severe asphyxia. He’s familiar with 8 serious adverse events over the past 2 years: 3 births had mechanical difficulties. 2 births had clearly abnormal CTGs (blindingly obvious ones, no dispute). But the 3 other births had CTG patterns where the outcome was unexpected. Again, glaringly unexpected.

How breech relates to shoulder dystocia:
25 years ago, the whole approach to shoulder dystocia was terribly primitive. Well-meaning providers would yank, shout, and scream. The baby might have a bad outcome and the staff would be traumatized. If you read textbooks from that time, one instruction was to apply firm traction on the head. That’s been reversed because even though the evidence is not watertight, we’ve systematized the whole approach to shoulder dystocia, and it’s made a difference. He no longer hears about people shouting and screaming. Rather, today it’s very quick and focused: We got the woman into McRoberts, we did this, we did that, we did the next thing, and the baby came out. The providers followed a series of steps clearly.

A similar thing is possible with breech for mechanical problems; we can make those births safer. Knowing the normal and the abnormal in detail allows us to prevent the majority of nasty mechanical problems in a breech birth. We have to keep thinking about it in a creative way, but it’s manageable.

The tricky question, however, is the issue of intrapartum monitoring and how the baby behaves as a breech vis-à-vis oxygenation. When a CTG is glaringly abnormal, there’s no argument. You do something. You act right away in cases of persistent bradycardia or persistent tachycardia. But most cases are in between these two extremes.

Making breech birth safer
There are 2 achievable goals in making breech birth safer: getting better at resolving mechanical difficulties and acting promptly in the case of clear CTG abnormalities. But that leaves us with the remaining breech births with bad outcomes in which the CTG monitoring does not indicate a problem.

The evidence for CTG
The next part of Andrew's presentation delved deeply into the literature on CTG monitoring. The evidence we rely on for fetal monitoring primarily comes from cephalic births. He referred to the 2017 Cochrane review, with regard to neonatal seizures. If you looking at high-risk subgroups, the effect of CTG on NN seizures is not as strong as with low-risk groups. That has an implication for breech birth. The nastiest outcomes we have are HIE, including perinatal death. If the effects more obvious in the low-risk group, that might argue for doing monitoring for breech births, even for low-risk breech births.

Whatever evidence we do have, it’s indirect. The critical point is that CTG monitoring halved NN seizures with no effect on mortality, no effect on longer-term cerebral palsy, but with an increase in cesarean/forceps deliveries. Andrew noted, though, that this short-term difference in NN seizures didn’t translate into longer term CP.

(Rixa's note: Andrew referred to an Irish study but I didn't catch the citation; perhaps it was the 1985 Dublin RCT of IP fetal heartrate monitoring?)

INFANT study
Next, Bisits discussed a recent study by Brocklehurst et al, the INFANT study (Lancet March 2017). It was a RCT of 46,000 women in the UK. All women had indications for FHR monitoring (traditional risk factors). They were randomized into two groups: CTG with or without computerized decision support. Preliminary evidence suggested that computerized decision support might lead to better outcomes by eliminating interobserver variation and thus more accurately indicate when intervention was needed. This was a very well-designed RCT. The trial groups had very similar demographics and a similar frequency of induction, epidural, cesarean, forceps, and spontaneous birth.

3 years ago, Brocklehurst said that if this study doesn’t show a difference in outcomes, it would really raise questions about the overall value and future of CTG itself.

Andrew noted that big money was fueling this study. He didn’t say this maliciously—but 7% of the NHS budget goes towards settling claims in cases that involve CTG. 7% of the NHS budget! No wonder there’s an incentive to get the best out of CTG and find ways to minimize these huge payout cases.

The study itself found no difference in outcomes between the two methods of CTG interpretation--this despite big hopes for this new computerized technology. The researchers followed the babies for 2 years after birth: still no differences. Andrew noted that some of the authors dropped out of the study because of the findings.

We’re in an ongoing quagmire regarding CTG in general. And it’s a very messy quagmire. Andrew noted that CTG monitoring is “welded into the fabric of maternity care” because of medico-legal pressures, rather than because it’s effective. Yes, it does have a marginal effect, but it’s not as much as it’s made out to be.

When he talks to solicitors about CTG, they tell him, “What we believe is the CTG. What we hear from the doctors, that’s all subjective. But when we see something on paper, that’s something we can all agree on.” Despite all of its limitations, we are stuck with CTG.

The major conclusion of the INFANT study was that we have to look at other ways of monitoring fetal oxygenation during labor. CTG has significant limitations in being able to reduce major hypoxic damage to babies.

What are the implications of the INFANT study for breech babies? It depends on how you interpret the study! Some people would conclude that you should be doing CTG, others would conclude you don’t need to.

Andrew next referred to a 2016 Finnish study on CTG in breech versus vertex delivery by Toivonen et al. The authors found that late decels and decreased variability were more common in breech labors compared to vertex labors. For example, late decels were seen in 13.9% of breech vs 2.8% of vertex deliveries, and decreased variability in 26.9% of breech vs 8.3% of vertex deliveries. Overall, the authors found that CTGs are different in breech labors compared to vertex; whether or not those differences are clinically useful is still in question.

Shawn Walker: Yes, I also felt that this study was interesting but not strongly useful for clinical outcomes.

Jane Evans: Why? Do more breech babies have shorter cords so they are pulled more? We need to figure out why. These are all the things that would affect that. Can we measure the stress levels of women who aren’t on CTG vs who are (via a swab)?

Andrew Bisits: Yes, you could do that. There are a number of theories about the cording of breech presentations.

ST-waveform analysis
The next study of interest was a 2014 study by Kessler, Moster, and Albrechtsen titled Waveform analysis in breech presentation (BJOG). The authors took a series of 433 breeches and 5577 vertex babies who were monitored with ST-waveform analysis (a form of fetal ECG, different than traditional electronic monitoring). In theory ST-waveform analysis provides a better assessment of cardiac oxygenation.

Has it proven to be so? Overall there’s no glaring benefit to ST-waveform analysis. There are some enthusiasts, but if you look at the hard evidence, there are no huge standout figures. The vertex group was a higher risk group overall compared to the breech group. See the following slide for details:

There were 3 breech babies with significant problems. See the following slide for details.

In the one case of fetal death, the ST monitoring didn’t suggest an abnormality, nor was it a difficult birth. Maybe there was something wrong with baby? In this case, the CTG provided a falsely reassuring result.

There were also 2 cases of moderate HIE. One was quite severe with nasty seizures. But it wasn’t picked up in the monitoring, nor was it a difficult birth. In the other case of HIE, there was some suspicion due to the CTG tracings.

Overall, 2 of the 3 bad outcomes were not picked up by fetal monitoring. This means CTG/ST has a falsely reassuring rate of 2/500. This compares with the rate of severe outcomes with cephalic high-risk births (2/500). Would this have been higher in the breech group without monitoring? This is the question that is tough to answer.

Main conclusions (from a dearth of evidence): 
There are no clear answers about CTG monitoring for breech babies. It’s hard not to recommend monitoring; the social, institutional, and medico-legal pressures are too great. It’s too welded into the fabric of our care. Andrew doesn’t like saying that, but he thinks it’s the reality.

We need to be clear with women about the effectiveness of monitoring, and then a decision can be made whether or not it is done. We also need to look for other methods of monitoring the baby’s oxygenation during labor. Perhaps we should consider the use of buttock lactate/ph. In the 80s, these came up with a lower than normal pH for breech babies. RCOG guidelines said it’s not recommended.

~~~~

Q from Julia Bodle: I’m thinking back to what CTG does and doesn’t do—halving the rate of NN seizures. What are the long-term outcomes for the babies who have NN seizures?

Andrew Bisits: There are 2 differing views on this.
1) In the follow-up from Dublin CTG trial, they could not detect an excess of CP.
2) If you read the Cochrane review and the comments that they invite after it, a Swedish researcher quotes a Swedish study that looks at grade-2 HIE and its longer-term implications. From this particular Swedish study, there is a 48% incidence of CP. Further, 18% of babies had some significant cognitive issue (not sure at what age). Only 25% were actually normal at age 15. NN seizures are not benign in the long-term, according to that Swedish study. I always believed in that Dublin data, so I’d need to look up the original study the Swedish researcher citing.

Andrea Galimberti: In the UK we tend to prefer intermittent monitoring when possible because women can move around. What is the difference between high-risk women monitored and the low-risk women who have intermittent?

Andrew Bisits: From a biological point, nothing! From a psychological standpoint, lots.

Q from audience member: What about other outcomes besides CP, such as ADHD, autism, etc. Have you read anything about this?

Andrew Bisits: There is a weak link with ADHD. The slightly concerning one is cognitive impairments noted at age 15-17. They’re the ones that have been reported in Sweden.

Q from audience member: Might it have more to do with NN management and cooling?

Andrew Bisits: We haven’t changed the instance of CP despite all these advances; it’s still 1/1000.

Q from audience member: There’s no good evidence that any monitoring improves the outcomes because nobody’s done the studies. Certain CFM has known harmful effects. We may be doing a lot of harm while trying to reduce these small things.

Andrew Bisits: In the cold light of day, I would agree with you. The problem is we’ve got this whole mindset that is welded—not by a thread—into the whole fabric of maternity care at all levels.

Q from audience member: Don’t we have to make sure we do no harm, first?

Andrew Bisits: We would hope, yes.

Betty-Anne Daviss: As a practitioner, we have to be very careful in Canada and stay very close to the SOGC guidelines not to raise the ire of the OBs in our unit. I think we have to start understanding what the normal breech is with some of our other parameters. I’m concerned that we’re making the decision about what a normal Apgar is for a breech baby, because Apgars are different for breeches. We have to normalize a low pH for breech babies. We have to put those together with the monitoring. We should start to write down things like floppy/not floppy that seem to raise our concern. As researchers, we need to start putting those things together for what the norm is for breech.

Emilano Chavira: There’s such an obvious parallel between pros/cons of CFM and the breech birth itself. For example, the presentation by Lawrence Impey focusing on all the outcomes of NN survival vs death, and acknowledging that it’s just one outcome and there are so many others we can look at. Your presentation looked at NN seizures/death…but what about everything else—maternal procedures, cesarean sections—that comes with monitoring? I’m very sympathetic about both the audience’s questions and with your presentation. Is there any option at all? Can we engage in informed consent for these things? What approach does the mother want to take? Maybe informed consent is a first step towards dislodging this “welding” that we have.

Andrew Bisits: Yes.

Julia Bodle: This INFANT study affirms my belief that the world is a much more corrupt place than I had thought it was. I just saw a press release from the company that makes the K2 Guardian CTG technology, the one used in the study, claiming that it reduces stillbirth and brain damage! K2 medical systems is sending these press releases out, clearly misrepresenting the evidence from the INFANT study. In fact, the RCOG and BFMFS just sent a joint statement warning people about this press release. I just got the notice yesterday in my email. It’s outrageous! On the upside, you can use this study in court in your defense; the type of monitoring doesn’t make any difference.

(Rixa's note: I can not find the RCOG/BMFMS statement online, but I did find this news release mentioning it. K2 Medical systems is making those claims by comparing the outcomes of the INFANT study with the outcomes of the BirthPlace study.)

Andrew Bisits: Do any units do intermittent rather than routine CTG for breech?

Julia Bodle: The current policy is to talk to the women, give them evidence, and then they choose. Our unit has a policy that it’s recommended.

Andrea Galimberti: We are discussing modifying the policy. And of course women can choose.

Read more ...

Andrew Bisits: Establishing a training course in breech vaginal birth in Australia

First Amsterdam Breech Conference, Day 2

Andrew Bisits

Establishing a training course in breech vaginal birth in Australia

Ruth Evers introduced Australian obstetrician Andrew Bisits. His hospital in Sydney sees over 4,000 births per year. Andrew is working on several initiatives to promote normal birth by establishing primary midwifery care for women. Women are traveling long distances to birth with him, because he’s the only one they can find to attend their births.

Today Andrew Bisits talked about an approach to teaching breech skills. In our current situation, we have several important obstetrical skills (breech, twins, forceps, deeply impacted head at cesarean, etc.) in a climate of decreasing skills and increasing litigation. What do we do? Right now, the pressure is towards cesareans for breech, for primips, for labor in general. That is one approach: a cesarean section for everyone. He remarked that it might sound flippant, but there is an "insidious" trend towards universal cesarean.

What we have to develop more imaginative ways of learning from:

• Simulation
• Experience
• Obstetric mannequins (such as the one at the hands-on training in Amsterdam—the mannequin was so lifelike that people were getting nervous during the simulated births!)
• Computer technology
• Reflection and discussion

We also need to focus more on being sensibly confident. The business of handling anxiety is such an important part of teaching. In our current, slightly neurotic social situation, people lose confidence despite (or perhaps because of) the numeration of all the risks.

Becoming A Breech Expert (BABE)
Andrew has developed a course for teaching breech skills called Becoming A Breech Expert (BABE) in 2012 with colleagues Caroline Homer, Anne Sneddon, and Helen Cooke. After helping organize a breech conference in Sydney in 2012, they wanted to create something useful that would further promote vaginal breech skills. It’s a multidisciplinary course between faculty and participants. It’s conducted via the AMaRE (Advanced Maternal and Reproductive Education) company of Australia. Instructors are volunteers, and course is copyrighted.

Andrew noted that this project (and, I would argue, this entire conference) is not just about breech birth; it affects the rest of maternity care and the way we care for laboring women.

How the BABE course works
The course focuses on an individual woman, “Wanda,” rather than starting with statistics and numbers. They wanted to put the focus on the reality of an individual with a breech baby.

Evidence--objectives
• Understand the evidence about breech birth
• Discuss how this informs our communication with women with a breech presentation late in pregnancy. Communicating numbers is tricky. Most people don’t add them up like a balance.
• Make use of the evidence in communicating with women.

Next they discuss ECV, since it’s part of the breech package. They show videos and make a strong plea that ECV should be enthusiastically encouraged.

They discuss the mechanics of breech birth. In Andrew's experience, once women see the mechanics, they say “aha! Now I get it. I feel much better.” It gives women an anchor from which to make a decision. They emphasize that this knowledge of the mechanics has to be hard-wired into everyone attending the birth. They talk about the practicalities of the birth (post dates, monitoring, what will happen in labor, is a breech harder or longer, do women have to have an epidural, induction/augmentation, etc.). He emphasizes that continuous monitoring is for litigation. If women don’t want it, they don’t have it.

They then watch a breech birth as a group, including things to learn from it, things he might have done differently today. He reemphasized the value of videos in learning breech skills (echoing Frank Louwen's admonitions to use videos as a primary learning tool).

They also present women’s perspectives on VBB. They have many stories of women who found it very difficult to negotiate for a VBB within the Australian healthcare system.

Dealing with the unexpected breech
They show a video of an unplanned breech home birth; the midwife was not planning on attending a breech and couldn’t transfer the mother. (The midwife showed the video at the 2012 breech conference in DC and asked for input on what she did wrong. At that conference, they gently suggested what could have been done differently.)

Creating a safe space for physiological breech birth
In this part of the course, women describe how they set up the birth space in the hospital so they felt safe. They also use the story of a midwife who traveled a long distance to have a breech baby vaginally in a hospital.

Hands-on stations
Using the Sophie obstetrical mannequin by MODEL-med, they do normal breech in different positions. They also practice abnormal breeches, including how to resolve difficulties with arms and heads. They practice breech births in many positions: semi-recumbent, H&K, and birth stool

Andrew noted that once the breech is birthing and the bitrochanteric diameter is out, the baby will birth. From the birth of the BT to the birth of the head, he’s most comfortable when the baby is out in 3 minutes. So once you see the umbilicus, give yourself 3 minutes. Once the shoulders are out, 1 minute. These guidelines aren’t dogma, but they give an anchor for people to make decisions from.

Counseling the woman with a breech
They partner up and practice counseling, with the audience interacting. They have to communicate more than numbers. It shouldn’t be all about risks, and it's important to keep positive.

The course finishes by reviewing essentials for a safe service and giving practical suggestions for providers.

They’ve done about 8 courses since 2012. The main issue is: will this make a difference, increase VBB, and make things better? He doesn’t know yet, but he’s waiting the results of one survey. He still wonders what the best way is to train providers in VBB.

Andrew's main conclusion was that breech skills can be taught. He made the analogy with shoulder dystocia. SD skills have taught very effectively with various approaches. Things have greatly improved over the past 2 decades with the systematization of training for SD. The same is doable for breech. His course is more than just mechanics. They encourage ongoing learning from each case. Even during cesareans for breech babies, he demonstrates the mechanics of VBB to show residents how it works.

~~~~~

Q: I have a question about communicating the numbers about vaginal breech birth. Yesterday, we saw different approaches of how can can do it. What is your suggestion?

A: I literally put the numbers on a simple table. The numbers I communicate are:

• PNMR for VB is probably around 1/500 to 1/700. 
• For cephalic babies, it’s probably 1/1200 to 1/1500. 
• For ECS for breech, it’s 1/2000 or less. 

I do similar things for trauma. Then I talk to that. If you want to have a good idea of the risks of breech compared to other modes of births, you have to look at a lot of numbers. I want to emphasize that these bad outcomes don't occur very often. Everyone has a different take on risk, and they will have to process it for themselves.

Read more ...

International Perspectives on Breech: Heads Up! Breech Conference

Day 1: 

Panel on International Perspectives

• Jane Evans (Independent Midwife, UK)
• Andrew Bisits (OB/GYN, Australia): has attended over 300 VBB, planned and unplanned, since 1990s?
• Marek Glezerman (OB/GYN, Israel) 
• Anke Reitter (OB/GYN, Germany)
• Michael Hall (OB/GYN, USA) 
• Moderator: Betty-Anne Daviss (midwife, Canada)

Each panelist talked about the breech climate & protocols in their own country.

Jane Evans: UK

Once the Hanna Term Breech Trial (TBT) trial was released, it took away women’s choice of a vaginal breech birth (VBB) in the UK with “horrendous speed.” Gradually over the last 12 years, women have been saying no to cesareans and turning the tide. Still, women's choices are mostly to have a cesarean at a hospital or to have a VBB at home with a midwife. There are some small outposts within Scotland, Wales, and Northern Ireland where hospital providers still have vaginal breech skills. But breech is politically very delicate right now. In England, there are 1 or 2 isolated units where VBB was continued after the TBT, supported by brave obstetricians. We are left with a nearly 100% c/s rate for breech in most hospital units within the UK. In the last few years, a few forward-looking units have started to set up breech clinics. These were supported by midwives and gradually received more support from OBs. That has nudged other OBs into being more open to VBB.

Today there is a small groundswell for VBB because of the observational research coming out on VBB and on the research about the risks of a high cesarean (CS) rate. We may be able to start developing more choices for women with babies in the breech presentation. For example, there’s a unit in Yorkshire with a skilled midwife; this unit receives breech referrals from the local OBs. There’s a breech clinic set up in Norwich and another in Scotland. We will need a lot of time to develop the skills needed for breech birth. It’s more hopeful in the UK than it was 3 or 6 years ago, when the first two breech conferences took place.

Jane works as an independent midwife. Because IMs have no malpractice insurance, hospitals have withdrawn privileges, which means the more skilled midwives have to transfer care to a less skilled provider if the woman wants to birth in a hospital. But largely the choice remains a CS at a hospital or a VBB at home.

Andrew Bisits: Australia

He was invited to participate in the TBT. He spearheaded a move to increase the numbers of VBB so they’d have sufficiently skilled providers for the trial. He was very skeptical when Mary Hannah read the protocol to them. He strongly felt that the TBT was not the best test for determining the feasibility of VBB. There were 6 participating centers in Australia. After the TBT, VBB was no longer an option in Australia. Everyone lost their skills "overnight." It came at a time when many legal pressure were mounting. There was a $12 million payout to a Cerebral Palsy baby, combined with other concurrent events, that led to a “hysteria” about the obstetric situation among OBs.

In this climate, the TBT emerged. The RANZCOG then advised the majority of women to have a CS, saying that some might choose a VBB—in reality, this meant that all women would have them. In 2006, RANZCOG revised their guidelines (PDF here) to be less restrictive. Dr. Bisits was called “mad” for doing VBBs.He commented that Marek Glezerman’s 2006 article Five Years To the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial in the AJOG “saved my ass.” (Full-text PDF available here.)

From 2000-2010, Newcastle John Hunter Hospital was the only in the country to offer VBB. Why? Some women strongly wanted it, midwives were keen to do it, and it provided an “important insight into normal birth. If we lose that, we lose an important source of insight in our training.” Continuing to offer VBB also served as an important antidote to the medicolegal anxiety which dominated obstetric practice in Australia. It was just too important, at his hospital, to give up VBB. It was an important exercise in watching these women engage and deal with the risks.

Recent developments in breech research and training
The SOGC's 2009 revised statement (PDF here) had a “very significant” influence in Australia. Dr. Bisits finds it a useful counseling aid for himself and his hospital. In 2010, he moved to Sydney for family reasons. He started a breech birth service at the Royal Hospital for Women. There was resistance from the OBs, but marked enthusiasm from medical trainees and midwifery staff. In 2011, another teaching hospital has started a breech clinic under Dr. Andrew Pesce and midwife Michelle Underwood. Now RANZCOG is proposing breech training workshops to re-skill obstetricians. This was supported in part by a dangerously difficult CS in which the woman died; she had a breech baby, was fully dilated and ready to push, but not allowed to. This unfortunate event played a significant role in shifting attitudes towards vaginal breech birth.

Now in 2012, there are a number of “born again breech enthusiasts” who recently advocated for VBB in the RANZCOG journal. Women's Healthcare Australia has organized a breech conference on Nov 30 2012 at the University of New South Wales, with over 100 people already signed up to attend. On day 2, there’s a breech skills workshop. They’ve also completed an audit of breech births in Newcastle from 1999-2010, which he’ll discuss in more detail this afternoon. There are planned ongoing breech workshops through ALSO and more positive emphasis on VBB in medico-legal seminars. He also mentioned some ongoing qualitative studies examining the experience of women embarking on a VBB.

In sum, VBB is now offered in 3 major teaching hospitals in Sydney. He hopes that a similar service will be established in each of the other capital cities. There’s an emphasis on detailed training using good birthing models (simulators). He noted that consumer and midwifery energy has driven most of these changes. It’s also been fueled by more research highlighting the importance & value of normal birth. Obstetricians are remain apprehensive about VBB, while midwives and medical students are more enthusiastic.

Marek Glezerman: Israel

Dr. Glezerman recently brought the Frankfurt team to his hospital in Tel Aviv, the Rabin Medical Center. It has 9,300 births/year.

You can’t talk about general percentages of VBB in Israel, because it varies widely between cities and hospitals. In Israel, there are 25 medical centers that have maternity wards, and they all track their obstetric statistics. One hospital in Jerusalem had a 38% VBB rate, but it closed last year. His hospital has a 14% rate of VBB. On average, the VBB rate was 7.4% for 2010. It’s about the same as at 2003. There was a decline through 2006, but then a rise after that.

When he was approached to join the TBT, he was enthusiastic about having a RCT. He was at Wolfson hospital at that time. He also got another hospital on board. When it slowly appeared that the TBT was on a wrong path, he felt somewhat responsible for the involvement of Isareal’s centers. He went out and gave talks about this; it helped to move the VBB rate up in the later 2000s. The rate of vaginal breech birth reached a peak in 2007 and 2009. Now it’s been declining in the past few years. It’s a question of politics, of being convinced about something, of geography, and of the people involved. He’s had to reconsider the strategies he was using to get hospitals to come back on board.

He lamented that there’s no discussion about the pitfalls of the TBT. There’s no discussion of VBB in the right setting being a good option. It’s like a power plant: everyone wants light and electricity, but no one wants the power plant in their backyard! Everyone might agree it’s a good idea, but hospitals are reluctant to be the ones offering it.

What tools should we use in trying to convince hospitals that VBB is a good option? 
Emphasize that we’re always comparing risks with risks, not risk vs. no risk. You also need to think of the woman’s future pregnancies, not just this one, when deciding between a cesarean and a VBB. We also need to focus on the risks involved with C.

Looking at the numbers of cesareans done in Israel in 2011, 15% of CS were due to malpresentation (most of those for breech). 37% of CS were due to a previous uterine scar (most were a previous CS, with a few myomectomies). A lot of that 37% were due to an initial CS for breech presentation. Overall, about 40% of CS in Israel are done because of past or present breech presentations. We need to stress that point.

Dr. Glezerman next discussed ISOG's (Israel Society of Obstetrics & Gynecology) evolving position papers on vaginal breech birth. He and some colleagues helped rework and revise the recent position paper. It recommends:

• “VBB should be offered as an option to carefully selected women under defined circumstances.” This also means that someone should be around who can offer it. 
• “ECV should be considered.”
• “Parturients should receive extensive information and give written informed consent. A senior obstetrician should be responsible for evaluation and delivery.” (In Israel, midwives cannot deliver a breech at hospital or at home.)
• “A pediatrician and anesthesiologist should be available at delivery.” (Not necessarily in the room, but on the premises)

This might seem a far cry from what should be the policy, but it’s the best they could get. At least now they have this position paper. It’s the major safety net for OBs performing a VBB if it comes to a medico-legal issue.

He wrote a recent commentary To rescue a vanishing obstetric skill--vaginal breech delivery in the journal Harefuah. 

Contraindications to VBB:

• EFW < 1500 g or > 3800 g
• Footling/incomplete breech
• Hyperextension of head (by ultrasound)

Considerations:

• Induction is optional
• Primiparity is not a contraindication (it used to be—there was a huge fight over this)
• Prematurity is not a contraindication

Dr. Glezerman acknowledged that some of these guidelines might seem overly restrictive, but tehy at least open the door for VBB. Once vaginal breech birth is well established, we may be able to loosen the guidelines somewhat. But we can’t risk a bad case right now; we need to ensure that we have a very selected group of women likely to have good results.

Importance of simulation-based training
Simulation training is used to train physicians in many medical and surgical fields. We need to implement simulation training for VBB too. Anke Reitter and Betty-Anne Daviss did a course on VBB using simulation training; 22 of the 28 residents at his hospital attended.

Dr. Glezerman ended his presentation by showing a pictures of the first H&K delivery at his hospital. Anke Reitter and Betty-Anne Daviss were present for the birth.

Before the next speaker, Betty-Anne Daviss added that Marek Glezerman and Frank Louwen took a huge amount of heat from skeptical obstetricians in Israel. We owe Marek a big congratulations for his efforts. She then introduced the next panelist, Anke Reitter, commenting that she had searched all over Europe for a unit doing vaginal breeches in an innovative fashion and became "glued" to Frankfurt once she found it.

Anke Reitter: Germany

Anke Reitter started her training well before the TBT and did a lot of VBB in Britain in a big unit in Liverpool. She often had undiagnosed breeches coming in. At the time, it wasn’t a big deal; she was trained from the senior OBs with no fear. When she came back to Germany, the TBT came out and everything had changed. VBB was rarely, if ever, done.

However, she noted that demand for breech and vaginal twins are coming back; as obstetricians we must be well-trained and train our juniors.

Contraindications to vaginal breech birth in Germany: 

• IUGR
• EFW weight > 3800 g (*she doesn’t at all agree with the 3800 g cutoff. She has found that the bigger the baby is, the easier it is to birth)
• disproportion (unclear whether this meant pelvic disproportion or head/body disproportion in the fetus)
• footling breech
• pelvic anomaly
• inexperienced OB

German guidelines dating August 2010 recommend: 

• ECV should be offered and must be part of special obstetric training 
• Clinical assessment of pelvis; MRI or x-ray not essentia
• do an EFW (“highest chance for a successful VBB will be in a normal size baby) 
• Unit should have an experienced OB on site, plus neonataoloigst and anesthesiologist (She asked *how many does this mean? How often? What does experienced mean?) 
• Prenatal counseling and information about the unit
• Informed consent for VBB

In Germany, ECV is done starting at 36 weeks. They use no tocolytic drugs or anesthesia for the procedure.

Pelvic MRI
In Frankfurt, every primip receives a pelvic MRI. An obstetric conjucate of  <12 cm leads to a planned cesarean. Primips with an obstetric conjugate of >12 cm can have a trial of labor. They don’t look at any other parameters other than the obstetric conjugate.

The Frankfurt clinic does a lot of primip breech births: 70% of their vaginal breech births were with primips.Their numbers of vaginal breech births have doubled since 2004. A lot of women travel to their clinic to have a breech birth. They are an island in how they approach breech birth. In many other hopsitals in Germany VBB isn’t really an option. Because of that, they’re very exposed and have to adhere to relatively conservative guidelines.


Dr. Reitter showed this flow chart for her unit's exclusion and inclusion criteria:

Women who fall into the following categories require a prenatal work up:

She compared her unit's outcomes to the PREMODA and Dublin data. You'll notice that the Frankfurt clinic has a higher rate of planned VBB and a lower rate of successful VBB than the PREMODA study. Overall, however, a greater percentage of all women with breech presentations in Frankfurt have vaginal births.

If a woman plans a cesarean section for a breech presentation, they prefer to wait for labor to begin spontaneously or until around 40 weeks.

Women who live far away continue their prenatal care with their normal midwife or OB, then come back to the Frankfurt clinic during labor. They prefer for labor to begin on its own, but they may induce at 10-12 days postdates.

To conclude, Anke Reitter expressed her committment to physiological breech birth. Like Eric Bracht, she and Dr. Louwen "do not want to disturb the physiological process of a vaginal breech birth, we in fact want to support it.” From the hundreds of upright breech births they have done int he past decade, they conclude the following:

Our hypothesis is that the maternal position during labour impacts on the natural descent of the fetus, on the necessity of using manoeuvres or interventions, and on maternal and fetal outcomes. 

Take home messages:

• Upright position does expand the pelvic [dimensions] and therefore will facilitate labor and delivery
• This advantage should be used in all deliveries
• In pregnant women with normal pelvic measurements, a vaginal breech birth does not lead to any increased risk for mother and child

Michael Hall: USA/Colorado

There were only three minutes left in the session when Dr. Hall began speaking, so he had to abbreviate his comments.

Michael Hall, an obstetrician in the Denver area, expressed his frustrations that he couldn’t get ACOG representatives to attend this conference, despite extensive efforts by him and other physicians. He is a fellow of ACOG but not spokesman for the organization. He’s in the trenches, not an academic OB/GYN. He has recently received privileges at a teaching hospital in Denver so he can start teaching the residents vaginal breech skills. It took a year to get privileges.

He has met a lot of resistance from his peers about attending vaginal breech births. Pediatricians are particularly resistant to VBB, since breech babies come out needing assistance more often than vertex babies. However, he keeps on doing it and doing it. Now his local hospital is comfortable with it. His nurses now are very comfortable with VBB and very respectful of him. But it’s a long process to get there. It’s not whether or not we can do VBB. We can do it. Most of obstetricians know how to do it. But many don’t want to. If they see some of their peers doing it again, then we can make some inroads.
. 

Read more ...

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

Read more ...

Selection of Candidates for Vaginal Breech Birth: Heads Up! Breech Conference

Day 2

Selection of Candidates:

Factors to Consider 

Panelists

• Andrew Bisits (Australia)
• Martin Gimovsky (USA)
• Jane Evans (UK)
• Sophie Alexander (Belgium)
• Marek Glezerman (Israel)

The panelists answered the question: What are your criteria for a vaginal breech birth?

Andrew Bisits prefers a woman who is informed, along with her partner, and is motivated. He looks for a good level of understanding and cooperation. He always feels better about the situation if there's continuity of midwfiery care.

• EFW <4000g 
• Baby not growth-restricted
• Presentation of baby prior to labor doesn’t bother him. He looks at presentation at the onset of labor; he will advise CS for footling at onset (but he doesn’t always do a CS in this situation).
• Labor progress: once the woman is in established labor, she should progress roughly ½ cm per hour. You’re not necessarily watching the clock; these are just overall guidelines.
• Pushing stage: if the baby is not descending after an hour, he will start asking himself questions. After 2 hours, he will definitely advise a CS.
• Does not exclude primips.

He uses ultrasound to assess the baby’s weight. He doesn’t do pelvimetry. He used to, but he found it distracted him from the criteria of labor progress. He uses continuous monitoring during labor. If a woman strongly does not want cEFM, they will come to a compromise agreement.

Dr. Martin Gimovsky agreed with everything Bisits said. In additon, he can never stress enough the importance of support people (labor nurses, doulas) besides midwives and physicians. The key to VBAC or VBB is to go for the low-hanging fruit. He’d much prefer a mutlip frank breech than, say, a primip footling breech that weighs 4000g.

He was trained to measure the pelvis for all babies. He uses cEFM and CT pelvimetry. With a breech baby, a prolonged active phase of labor is a sign for concern. Dilation: the cervix dilates as the muslce fibers are taken into the uterus, not depending on the presenting part. Thus he feels epidurals are acceptable if the patient uses them. They do cord gases after the birth. The pediatricians are always unhappy with him and others who do VBB. An ideal candidate: frank breech, 37-42 weeks, EFW under 4 kg, woman comes in in active labor. Primips or multips are okay. He is more concerned than others about pelvic capacity and feels a CT scan is advisable.

Primary principle: first do no harm
Second prinicple: patient autonomy

Midwife Jane Evans noted that her parameters as a midwife are wider since they take on women who have no option of VBB in a hospital. Her first prenatal visit is 2-3 hours long. She ensures women have all the information on all of their options. She only has access to one hospital in her area, so mostly vaginal breech birth is done at home. Many of the women want to start labor spontaneously. She doesn't have a criteria for the baby’s presentation. If a footling comes down too early, have the mum lie on her left side and tickle the foot gently. The baby will tuck it it back up inside. As long as we have progress throughout the labor and 2nd stage (and don’t forget the placentas!) and baby and mom are okay, we await and facilitate the birth.

Q: What size of babies are you catching breech?
Her breech babies range from 2750-5000g. The average weight is probably 3000-3500 g. If a nice fat, well-grown bum doesn’t go through, the head won’t go through. IUGR is a contraindication; she uses her hands to determine this. She “palpatimates” the size of the baby. She feels she’s more accurate than a scan in determining IUGR.

Dr. Sophie Alexander of Belgium remarked that she works in an entirely different context from Jane Evans. In her country, if a woman has a breech baby, the guidelines say you have to offer or dicuss the option of a VBB. Most of their criteria have evolved from tradition as taught by older OBs. She follows her College guidelines strictly. These include:

• Routine scan at 32 weeks to determine presentation
• 32-37 weeks if breech
• talk with mother/parents
• discuss options if baby remains breech and ECV fails. Give her access to full information (i.e., TBT and PREMODA)
• tell her she can use positional or moxa interventions but there is not good evidence
• reinforce motivation for physiotherapy (kinesitherapie) unless she is really sure she prefers and elective cesarean section
• Attempt ECV at 37 weeks, unless woman has objection or contraindications
• If ECV fails,
• CT or MRI pelvimetry
• Ultrasound for EFW
• Prenatal visit to explain the process of breech, emphasize the need for teamwork

Criteria for vaginal breech birth at term:

• Adequate pelvimetry 
• EFW 2500-3800g
• Not footling
• Flexed head in labor
• In Belgium, there are mixed practices on allowing primips, nuchal cords, and full (complete) breeches
• A previous cesarean will have a repeat cesarean if labor doesn't begin by 42 weeks

Admission guidelines:

• Confirm frank or complete (full) breech
• Confirm head flexion
• Be sure labor is well-established before admission

In labor:

• If the woman departs from the partogram, allow only twice two hours to get back into a normal labor pattern. Can augment with oxytocin for 2 hours. If still no progress, try ARM and wait 2 more hours. If still no progress, suggest cesarean section. 
• Epidural is a general rule for all women attempting VBB
• At 9 cms, inform the OB, pediatrician, anesthetist, & midwife
• At full dilation:
• allow passive 2nd stage for up to 60 minutes
• then put up oxytocin drip and start pushing
• pushing should bring some descent within 20 minutes and birth within 60 minutes, otherwise move to cesarean
• birth should be expedited if there are anomalous FHR or breathing attempts

Dr. Alexander acknowledged that these guidelines are quite strict. However, vaginal breech birth is politically delicate and one bad outcome could mean the end of VBB. They have to be careful to stick to the rules--as much as she has some personal frustrations with them

Dr. Marek Glezerman commented that we all want mostly universally acceptable criteria. In Israel, he has no choice but to adhere to the guidelines (which he helped write!).

Choosing the right vaginal breech patient means you’re already there—you already have the skills, the motivated patient, and the safety net. Unforutnately we’re not all in this ideal situation yet.

He posed some interesting questions:

• What about emergency breech delivery, where there’s no time for choice or discussion? What if you have no access to skills on premises?
• What about comparative risk assessment?
• How do we convince OBs, the public, or the courts that VBB is a viable option? Don't ignore the reality of the medico-legal environment. We need to convince courts that risk assessment means looking at all aspects of the situation, not just at the risks of vaginal breech birth. 
• And most importantly: Why are there so few OBs in this room? The conference organizers said there were 10 OBs in attendance, not counting the speakers. But there should be hundreds at this conference!

Dr. Glezerman also contrasted the ideal world vs the real world. If you cannot avoid complications or disaster, you better be prepared. There will always be situations where you need to deliver breeches vaginally. Unfortunately, we have buried or lost our skills. Three generations of residents have never had the chance to learn VBB, so we cannot offer choices. Everyone is on their own.

Ethical limits of autonomy:
Autonomy means both the right to choose and the right to refuse treatment. But it’s not the same as the right to demand treatment. (I wish he had further expanded on this point. Is a vaginal breech birth "demanding treatment"? Or is the inevitable consequence of refusing a cesarean--since it will occur on its own? These questions apply equally well to VBAC, since refusing an elective repeat cesarean will inevitably end in a vaginal birth after cesarean, making it less of a "treatment" and more the physiological result of pregnancy.)


How do we convince those who are opposed to offering vaginal breech birth?
We need to use the right tools. We can’t use only moral reasoning. OBs have been trained to listen to data. We have to focus on the risks involved with cesarean sections. CS is not just another delivery mode; maternal mortality for elective CS is 3x higher than for vaginal birth. There are incidental and consequential morbidity from cesarean surgeries. What price does the public pay for higher rates of CS? Cesareans have an impact on future reproduction, higher maternal mortality and morbidity, longer hospital stays, higher stillbirth rates, placental abruption, placenta previa, and more. Placental pathology is “The Great Risk Factor” with cesarean section. 50% of all emergency hysterectomies are done for placenta previa or placenta accreta. The risks increase exponentially with each additional CS.

Overall, cesarean section carries more risk for the mother than a vaginal birth. If so, is it better for the baby?  No. Cesarean section is associated with higher fetal/newborn morbidity, respiratory problems, bonding/feeding problems, prematurity, etc. There is unequivocal data showing increased risk to the baby from cesarean section. 

Arguments for reviving vaginal breech birth:

• Because CS is more risky for mother
• In well-chosen women there is no advantage for the baby compared to CS
• There is not always a safe alternative
• Women's right to choose
• For when CS isn’t an option
• For the second twin
• To reduce unnecessary CS
• To prevent subsequent CS
• During a cesarean surgery: you still need to be skilled in breech delivery techniques to be able to delivery a breech baby or a deeply lodged vertex baby safely! 

He referenced several studies:

• Chopra S et al. Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: Conventional method versus reverse breech extraction. Acta Obstetricia et Gynecologica Scandinavica. 88.10 (Oct 2009): 1163–1166.
• Kolas et al. Planned cesarean versus planned vaginal delivery at term: Comparison of newborn infant outcomes. AJOG (2006) 195, 1538–43.
• Rageth et al. Delivery after previous cesarean: a risk evaluation. Obstetrics & Gynecology. 93.3 (March 1999): 332-337.

Read more ...

Breech Research: Heads Up! Breech Conference

Day 1:

Panel on Breech Research: 

Looking Back and Looking Forward

Dr. Andrew Bisits

Andrew Bisits presented data from term breech presentations at John Hunter Newcastle Hospital collected between October 1999 - December 2010. He also suggested some future directions for research and training, including good rigorous prospective data collection, ultrasound study of births, use of high quality simulation models, and qualitative research into women's experiences of breech.

Last, Dr. Bisits commented that the physicians during this time period (1999-2010) had to be very cautious because of the delicate political situation surrounding breech birth. They were under quite a bit of pressure to react at the slightest sign during a breech labor.  He was surprised by how happy women were to have had a chance and a choice, even if they ended up with a CS after attempting a VBB. 

Dr. Anke Reitter

Dr. Anke Reitter began by briefly reviewing the implications of the TBT in Germany. She wasn’t very shocked by the findings of the TBT, based on how it was designed. There has never been a strong breech advocacy community in Germany; she doesn’t think anything like the Coalition for Breech Birth would be possible there. She also mentioned Marek Glezerman’s 2006 critique of the TBT, Five Years to the Term Breech Trial, which she felt was extremely important in changing the course of breech birth. In Germany, the rate of VBB fell after the Hannah Trial. Multips had a small but decent chance at VBB before the TBT, while primips rarely did, even before 2000.

She told Dr. Frank Louwen’s moment of inspiration when he looked at illustrations of vaginal breech births upside-down. He realized that if we turn a woman over, we won’t have to do as many maneuvers and that the breech can deliver itself. Dr. Reitter called for new terms for this new spontaneous kind of birth on H&K.

Next, she presented the results of a research study on maternal positioning and pelvic dimensions (publication forthcoming). She briefly referred to another study using MRI for breech presentations (Van Loon et al. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term. Lancet 1997; 350: 1799-1804.) This study concluded that using MRI did not significantly reduce the overall cesarean rate, but it did lead to a lower emergency cesarean rate during labor.

She finished her presentation by showing illustrations of two new maneuvers for helping assist upright breech births and mentioning the Frankfurt study of upright breech positioning, which she and Betty-Anne discussed in more detail the following day.

Marek Glezerman

He still keeps talking about the TBT 12 years later because so many of his colleagues still cite that article and don’t acknowledge any of the newer studies. He spent most of his presentation outlining the strengths and weaknesses of the TBT. I highly recommend reading his 2006 article Five Years To the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial (full text PDF here).

The TBT was a perfect fit for the medico-legal climate in obsetetrics at the time. It was fast-tracked for publication in only three weeks. Almost overnight, the entire Western world stopped doing vaginal breech births. In contrast, the 2-year followup study (White et al) took 2 years to be published. This study found that planned CS is not associated with reduction of risk of death of neurodevelopmental delay in children 2 years of age, “but more parents in the PCB groups than the PVB group reported that their children had had medical problems in the past several months.” Even though this analysis found no difference in long-term outcomes, it was too late. Except for a few isolated hospitals and providers, vaginal breech birth had gone extinct.

Dr. Glezerman's 2006 critique of the TBT attracted a lot of heat. But it also was highly influential in softening ACOG, RCOG, SOGC, and Cochrane guidelines on vaginal breech birth.

Ohter articles Dr. Glezerman referenced:

• Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol (2002) 99: 1115–1116. 
• Whyte H et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial. Am J Obstet Gynecol (2004) 191(3): 864-71.
• Schutte JM et al. Maternal deaths after elective cesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand. (2007) 86(2): 240-3 . This study found that ECS does not guarantee the improved outcome of the child, but may increase risks for the mother. Cesareans for breech presentation was responsible for 7% of total direct maternal mortality in that period (4 maternal deaths in 3 years). 
• Goffinet F et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. AJOG (2006) 194: 1002-11. Usually referred to as the PREMODA study. Dr. Glezerman commented that a good ITT (intention to treat) study, such as PREMODA, is certainly is much better than a bad RCT. 

Marek ended his presentation with a call for reviving vaginal breech skills. These skills are essential not just for women who actively seek VBB or who present late in labor with an undiagnosed breech. Physicians also need them during cesarean sections.

He discussed a fascinating study on difficult vertex cesarean sections when the baby's head is deeply lodged in the pelvis. Obstetricians typically use the "push/pull" maneuver (push the baby's head up out of the pelvis, and then pull the baby out of the incision head-first) to deliver the baby. However, this method is associated with 10x greater maternal trauma than a with a "reverse breech extraction"--where the obstetrician delivers the vertex baby bum-first from the fundus.

Here's more information on the study. Email me if you'd like the full text.

Citation: Chopra S et al. Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: Conventional method versus reverse breech extraction. Acta Obstetricia et Gynecologica Scandinavica. 88.10 (Oct 2009): 1163–1166.

Abstract: Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as ‘cephalic’ with or without assistance to push up the fetal head from the vagina (head first or push method) and ‘reverse breech extraction’ (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at ≥7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during ‘cephalic’ delivery as compared to ‘reverse breech extraction’ (22.8% versus 2.2%; p = 0.001). Use of ‘reverse breech extraction’ is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.

Read more ...

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.")

Read more ...