Vaginal breech workshop in Decorah, IA Oct 13-14

Announcing a Breech Workshop in Decorah, IA on Oct 13-14! Please spread the word so we can re-teach breech.

I will be giving 4 lectures: evidence on term breech, breech maneuvers, breech nomenclature & risks/outcomes, and breech birth at home.

We have also two fantastic instructors for the hands-on skills portion. Cynthia Caillagh, with experience attending over 550 breech births, and Dr. David Schwartz, a family practice physician in Waukon, IA.

Livestreaming will be available if you cannot come in person or if you get called away to a birth.

ACNM & MEAC CEUs available.

Scholarships available (priority for single parents & LGBTQ birth keepers)

Click here to register

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What freediving taught me about neonatal resuscitation

This semester I am teaching a class with the theme "Exploring the Limits of the Human Body." We are currently reading Deep: Freediving, Renegade Science, and What the Ocean Tells Us About Ourselves by James Nestor. This book is a fascinating narrative that combines ocean exploration, marine biology, competitive and research freediving, and dormant human abilities that originate in our deep oceanic past (the mammalian dive reflex, magnetoreception, and echolocation).

When freedivers experience a blackout--usually near the surface at the end of their dive--they still remain responsive to sound. After pulling the unconscious freediver to the surface, the safety team will call the diver by name and tell them to breathe: "Breathe, Alexy, breathe! Breathe, Alexy, breathe!"

~~~

From my time in the home birth world, I often heard midwives talking about how they involve parents in neonatal resuscitation. A common practice is to have one of the parents speak to the baby and encourage them to breathe.

I had always categorized this practice as a nice idea. It certainly wouldn't hurt, right? In fact, I did it instinctively when Inga was born; she lost color and tone after about 30 seconds and needed mouth-to-mouth. While I was resuscitating her, I was talking to her and encouraging her to breathe.

However, I never thought that there was a scientific or physiologic reason for calling the baby by name and telling them to breathe--until I learned about freediving. Even when all of their other senses are offline, a blacked-out freediver will still respond to sound.

~~~

Calling a baby by name and telling them to breathe, especially when done by a familiar voice, isn't just fluffy woo-woo. It's part of our basic physiology.

This was a lesson in giving more respect to the instinctual or "homespun" practices that have evolved with midwifery and home birth. How many other traditions have yet-to-be-discovered science behind them?

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Ivy's nursing party

Every time one of our children decides they are done nursing, we have a nursing party. We make or buy a cake, we nurse one last time, and then we eat the cake!

Zari was 3 1/2 and chose a strawberry & whipped cream patisserie (we were in France at the time).

Dio was also close to 3 1/2 and wanted a Lightning McQueen cake. His wasn't fancy, but he loved it.

Inga was totally done right at 2 years. Not at all interested in nursing even after I had Ivy and was producing tons of milk. I made her a chocolate cake with blackberry frosting.

Ivy has nursed the longest of everyone, several months past her 5th birthday, probably because I didn't have any other babies :) Finally she decided that she was ready for her nursing party.

So yesterday, Ivy dressed up in one of her favorite outfits, brushed her hair, and placed her barrettes in rainbow order. We walked to one of my very favorite patisserie shops, Lac. We each chose our favorite patisserie. She walked home oh-so-carefully carrying the fancy box tied up with a ribbon. We nursed one last time--the last time in my entire life! I'm going to cry! Then we ate our "nursing cakes."

I've been breastfeeding for around 11 1/2 years straight, ever since Zari was born. I'm sad and happy at ending this part of my life.

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These are my hours

These are my hours. Let them be hard. I’ll ask for what I need.

This is one of the few lines of narration in the entire documentary These Are My Hours. Filmed entirely during one woman's labor, it is the first of its kind. I'm not one to use hyperbole, so when I say that this film was revolutionary and ground-breaking and magnificent and shattering, I mean every word.

The cinematography was stunning, capturing angles and moving shots that would have been nearly impossible to choreograph--even to imagine. And let's not forget the key reason behind this film's success: Emily Graham. Her expressive face and body. Her self-monologues that range from soulful to comedic. Her deep physicality and instinctuality. Her ability to make me feel like I was there, not just watching her but there, inside her body, living the experience.

I loved that the film didn't end right at the baby's birth. Instead, we watch Emily adjust to her new body and come back to herself. We see that birth is a process with an ascent, a peak, and a descent. All three steps require navigation and integration. The descent can be just as beautiful as it has the weight of the entire experience behind it.

The filmmaker had up to 3 cameras operating simultaneously, yet I never once felt like anyone else was in the room. That was a gift and a skill on both the filmmaker's and Emily's part. The music was minimal but exceptionally powerful. And some of the scenes still take my breath away when I think about them. I won't spoil the surprise here, other than to say that you ought to watch the film. Now. It's worth every penny. 

These Are My Hours is not a documentary about giving birth--it is birth. It follows Emily Graham through her labor, birth, and immediate postpartum. Or rather, we journey with her, inside her, as part of her. Besides a handful of narrative sentences and Emily's labor monologue, the documentary is almost entirely wordless. Birth is a process that transcends language and involves all of the senses, so the film's focus on the bodily experience and the near absence of language, interpretation, or commentary was fitting. I still struggle to find words adequate to describe the experience of watching These Are My Hours--a testament to the documentary's success.

As I watched this documentary, I realized: birth can speak for itself. It needs no champion or interpretation. We just have to be willing to listen.

Disclosure: I was not paid to write this, and I purchased access to the film myself. 

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Aug 18-19 Breech Workshop in Auburn, WA

Come to the Aug 18-19 Breech Workshop in Auburn, WA sponsored by Dr. Rixa Freeze, Breech Without Borders, and the Washington Alliance for Responsible Midwifery (WARM).

CEUs will be available (ACNM approved; MEAC applied for).

If you can't come in person, you can livestream the conference. We will also be recording and offering the workshops online.

I am presenting four lectures on Aug 18th, mostly theoretical/informational. Aug 19th will be taught by WARM and will focus on hands-on skills and applied practice.

Online registration here.

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Obstetric violence--where #metoo births birth

Obstetric violence is a real thing. It's a form of physical and sexual assault. It comes in many forms--from little things like clamping the cord when the mother has specifically said "no," to big things like non-consensual episiotomies or cesareans. I've seen it happen as a doula, and I've written about it in my PhD dissertation.

This recent article by Sarah Yahr Tucker knocks it out of the park: Doctors Frequently Abuse, Coerce, and Bully Women in Labor, Doulas Say.

If you want to make a difference, please donate to the "Mother May I?" documentary. If you donate today or tomorrow, a generous donor has offered a $5000 matching grant. Only 6 days left to fund the documentary!

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Announcing...Breech Without Borders

I'm excited to announce a new nonprofit initiative called Breech Without Borders (www.breechwithoutborders.org).

Breech Without Borders is an organization dedicated to disseminating knowledge about breech pregnancy and birth. It helps information cross linguistic, geographic, and knowledge borders by:

1. Translating existing material about breech into multiple languages
2. Supporting breech research, publication, conferences, lectures, and training workshops
3. Making information about breech more accessible and understandable to both health care providers and to the public

Our website is a placeholder site until we can get a professionally designed site created. We already have a few translations done in French, German, and Dutch.

If you have a skill that you would like to contribute to Breech Without Borders--illustration, graphic design, translation, accounting, grant writing, etc--please get in touch with me.

Here are a few things we need help with specifically:

1. Someone to serve as Treasurer on the Board of Directors--preferably with accounting experience and/or familiarity with the financial requirements of US nonprofits.

If you can help in this capacity but don't want to be on the Board, I'd love you bring you on as an adviser to the Treasurer. (We have one volunteer already for the position, but she isn't familiar with US nonprofits, so I'm still open to finding a person with the right background).

2. Someone with medical illustration skills. I have several projects that need a series of illustrations.

3. Translations! We can always use more volunteer translators.

I'm in the process of writing the articles of incorporation and registering the nonprofit with state & federal governments. I'm really excited to get this project started!

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Illustrations of the breech mechanisms from a 1908 French textbook

This textbook by Farabeuf and Henri V is over a century old, but the illustrations are still some of the best I've ever seen. The attention to detail, the lifelike appearance of the fetus...beautiful.

These are the complete set of illustrations from the chapter on the mechanisms of breech birth. There are other chapters on how to diagnose type of presentation by touch, interventions (maneuvers), and how to perform but full & partial breech extractions.

To reflect today's increased interest in upright breech birth, I have rotated some images to keep the maternal spine consistently upright.

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10 mechanisms of upright physiological breech birth

This short video shows 10 key mechanisms of a normal upright breech birth.

1. Buttocks/feet emerge sacrum-transverse
2. Body restitutes to sacrum-anterior as trunk is born
3. Legs release spontaneously
4. “Cleavage” indicates arms are not behind head
5. Baby does tummy crunches to bring down arms & flex head
6. Arms release spontaneously
7. Full perineum = head is flexed
8. Head releases spontaneously
9. Baby passed to mother
10. Cord left intact even if resuscitation is needed

When these mechanisms are present, there's no need to do anything other than catch the baby. Approximately 70% of upright breech births will occur spontaneously with no need for any hands-on maneuvers. See Louwen 2017 for more information.



The original footage is taken from a longer video of a Brazilian couple whose planned homebirth ended up at a hospital due to breech presentation. I wrote about it several months ago here.

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Need help starting a breech-related nonprofit

I have an idea for a breech-related nonprofit organization. I think it's an amazing idea, and it dovetails nicely into the work I've already been doing with breech.

Illustration by Eloïse R. and used with permission

Here's a brief vision of what this nonprofit would do:

1) Translate breech knowledge across languages & geographic borders. This could involve translating research articles, presentations, lectures, blog posts, birth stories, guidelines, etc. I want to do English to multiple languages and vice-versa.

2) Translate medical knowledge and research about breech into information that regular people can understand.

3) Make research and information about breech more accessible to doctors and midwives--most of whom don't have the time or interest to do all the heavy research and analysis.

I have an amazing name already picked out, but it's SUPER SECRET for the moment.

If I were to get this going, I'd need help with the following:

• setting up the 501(c)3 nonprofit
• website creation & hosting
• graphic design (because looks are important!)
• managing finances/accounting
• people willing to serve on the board of directors
• grant writers
• $$$ to help fund all of the above

And most importantly...translators!!!

I want to start with French, Spanish, German, and Russian and then add as many other languages as I can find translators for.

If you're interested and/or can contribute in some way, please PM me on Facebook (preferred) or send an email. I'll add you to a Messenger conversation and we'll go from there

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Ski week at Vialattea

We got back from a week skiing in Vialattea, an inter-connected group of ski resorts in Italy & France (Sestriere, Sauze d'Oulx, Pragelato, Claviere, Cesana, Sansicario, and Montgenèvre).

We had lots of misadventures:

1) Our 2004 Opel Zafira broke down just as we got onto the freeway. The clutch was toast. We had to hobble back to Nice in 1st gear with the engine smoking. The repair would have cost far more than the car was worth, so we ended up buying a new (to us) car.

2) As Eric was packing the skis into the back of the (new) car, someone opened up the front door and stole his purse: wallet, phones, French visa, driver's license, credit cards, everything. What audacity. The thieves got away with a grand total of $30 USD, a book by Dan Chaon, and a nice leather purse that I made Eric several years ago. I'd rather pay people money NOT to steal his wallet as it's a pain to replace everything.

3) We got stuck in an icy parking lot and had to use our chains to get out. It was the only time we needed the chains, though, despite huge snowfalls right before we arrived.

4) The back of Zari's ski boot broke off while she was skiing in powder. I've never seen this happen before! She had to go down the mountain on one ski and buy new (used) boots.



Even when we weren't on the slopes, we had fun during our ski week.



Ski bloopers

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Happy 7th birthday Inga!

A smile full of new teeth coming in, boundless energy and enthusiasm, solitary at times, talkative at other times--that's our Inga.

Inga's birth story, part 1
     Part 2: Reflections
     Part 3: Resuscitation
     Part 4: Final reflections
1st birthday
2nd birthday
Inga's weaning party
3rd birthday (which I missed because I was in Seattle with Eric and Ivy...)
4th birthday

5th birthday

6th birthday

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French advice on nonfrank breech birth: apply counter-pressure to the emerging foot/feet

I'm wading through obstetrical literature of the 1980s & 1990s to discover information relating to type of breech presentation and the associated risks/outcomes.

In a 1981 article by J. Dubois, Some present aspects of the problems of breech presentation and delivery, he gives advice on attending nonfrank vaginal breech births. From p. 489:

#6. The nonfrank breech. We have already seen how it can pose some particular problems. If one decides to attempt a vaginal breech birth, one should take, at a minimum, 3 precautions: keep the membranes intact until full dilation; be on guard for cord presentation or cord prolapse; at the moment of expulsion, slow the emergence of the foot/feet for at least a little while by pressing one hand against the vulva.

By implication, the last precaution refers specifically to breeches emerging feet-first, aka footling breech, and perhaps also to a complete breech with the foot/feet slightly in front of the buttocks. The French obstetrical nomenclature doesn't generally have a specific term for footling, just nonfrank (siège complet) and frank (siège décomplété).

The last part struck me, as it echoes a technique proposed by Russian obstetrician Tsovianov, the Tsovianov II. This maneuver converts a footling breech into a complete breech.

Antonín Doležal. Porodnické operace. 2007

Dubois' recommendations do not mention the goal of converting leg position, but that could be a side result of counter-pressure against the feet. This technique could provide additional time for the cervix to dilate, if not already fully dilated.

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Severe acute maternal morbidity (SAMM)

Severe acute maternal morbidity (SAMM) is a maternal life-threatening event shortly before or after childbirth, often referred to as a "near miss."

Mantel et al (1998) describe a near miss as "a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death." In other words, "A very ill pregnant or recently delivered woman who would have died had it not been that luck and good care was on her side."

In 2010, van Dillen et al published a study about severe acute maternal morbidity in The Netherlands. Following all pregnant women nationwide, they found that SAMM occurred 6.4 times per 1000 after elective cesarean section, compared to 3.9/1000 after planned vaginal birth. The risk of SAMM after a cesarean section persisted into the next pregnancy. The authors report: "Women with a previous CS were at increased risk for SAMM in their present pregnancy."

I created an infographic that represents those findings. Whenever a woman faces the possibility of a cesarean section, the short- and long-term risk to herself should be part of the discussion.

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Can we predict the likelihood of a successful vaginal breech birth?

How likely is a woman to have a cesarean when she is in labor with a breech baby? Is there any way to predict her chances of a vaginal birth based on how dilation and estimated fetal weight?

A teaching hospital in Liverpool compiled data on all singleton term and near-term breech babies born in their unit between 1988 and 1991. Nwosu et al (1993) calculated the likelihood of having an in-labor cesarean based on both estimated fetal weight and cervical dilation at admission. They explain:

Recently Chadha et al (1992) have shown that women admitted in labour with breech presentation at a low cervical dilatation (less than 3 cm) are more likely to be delivered by caesarean section. This is in agreement with our study. Using our results for all vaginal and emergency caesarean deliveries, we are able to tabulate the likelihood of caesarean section corresponding to various values of cervical dilatation on presentation and estimated fetal weight. These results are presented as Fig. 1 (Callygram), which could assist the clinician on the labour ward in counselling the woman, and in the choice of the best mode of delivery. It must be stressed that the tabulated (percentage) probabilities of caesarean section for given values of cervical dilatation and fetal weight are derived from our sample which has not specifically addressed the question of augmentation of labour [this unit did not induce or augment] and intrapartum external cephalic version (with or without tocolytics).

As you can see, the likelihood of a successful vaginal birth increases significantly with higher cervical dilation at hospital admission. EFW also plays a role, but that difference nearly disappears at both extremes of cervical dilation.

Cervical dilation at admission depends on how long the mother waits to go in, so this is a tricky thing to use as a predictive measure. There is no automatic set point at which women go to hospital (or, at home, call their midwife). A woman's likelihood of a vaginal breech birth also varies widely by hospital and by provider. But this does suggest that a rapidly progressing labor is a strong positive indicator of a successful vaginal breech birth.

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How does the 2000 Term Breech Trial compare to more recent evidence on term breech?

Recent studies do not support the findings of the 2000 Term Breech Trial, a randomized controlled trial that enrolled 2,088 women.

Two large multi-center studies in France and Belgium found no difference in perinatal/neonatal mortality between planned CS and planned vaginal birth. These studies--one prospective, one retrospective--followed a total of 10,200 women and had 174 & 175 participating hospitals.

Some national registry studies have found no significant differences between planned CS and planned vaginal breech birth.

A meta-analysis and other registry studies have found some advantage to planned CS, but the advantage is significantly less pronounced than in the Term Breech Trial.

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What would happen if all Dutch women had a planned c-section for breech?

Each year around 6,490 women in the Netherlands (40%) still plan a vaginal breech birth. This number is significantly lower than it was before the 2000 Term Breech Trial, where roughly 75% planned a vaginal breech birth and around 50% overall gave birth vaginally to their breech babies (see Rietberg et al 2003).

A national registry study by Vlemmix et al (2014) calculated the anticipated neonatal benefits if these remaining 6,490 Dutch women all planned c-sections.

If all women who nowadays still undergo a planned vaginal breech birth were to receive an elective cesarean, 6490 more elective cesareans would be performed. This would lead to an additional annual reduction of 10 neonatal mortalities, 116 neonates with low Apgar scores and 20 neonates with birth traumata.

This calculation only considers short-term neonatal benefits--not long-term neonatal outcomes, not short- or long-term maternal outcomes. Here is another way of understanding these numbers:

In several national registry studies, planned CS for breech leads to small but measurable improvements in short-term neonatal outcomes (mortality and morbidity). However, these improvements are consistently much smaller than the Term Breech Trial's findings.

This pressing question remains: at what point do the short- and long-term risks of routine cesarean begin to outweigh the short-term benefits to the baby? How many elective cesareans are justified to save 1 baby? What if women are forced into having these cesareans?

A policy of routine cesarean for breech does not allow women to decide what the acceptable risk/benefit trade-off is.

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Hike to Villefranche and Mont Alban

Last Saturday we hiked the Circuit du Mont Alban. So many stairs!

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Risk-benefit calculus for breech presentation

Making a decision about how to birth a breech baby involves a complex risk calculus. Women have to weigh the short- and long-term benefits to themselves, their babies, and their future pregnancies. This graphic (created for me by Lauren McClain of Better Birth Graphics) shows how planned CS for breech has affected women and their babies in the Netherlands. Verhoveen et al (2005) discuss the effects of the increase in planned CS since the Term Breech Trial, and the results show a risk trade-off.

Between 2001-2005, 8,500 women in the Netherlands had a planned CS for breech. This increase in pCS saved an estimated 19 babies, but it also led to 4 direct maternal deaths, 9 additional babies dying in future pregnancies due to the uterine scar, and 140 additional life-threatening maternal complications in future pregnancies.

Alternative version of the graphic with text embedded in the image:

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Perinatal mortality in term breech birth

In preparation for my Jan 24th Indie Birth webinar--Is vaginal breech birth safe?--I wanted to share this series of graphics I have created. These will be explained in more detail during the presentation.

This first illustration shows neonatal and/or perinatal mortality rates from the Term Breech Trial, two large multi-center studies in France & Belgium (PREMODA and Vendittelli), a meta-analysis of several single-center studies (Krebs), and then a series of national registry studies.

These are all studies of term breech births of singleton fetuses alive at the beginning of labor with congenital anomalies excluded (exception: the TBT also included antepartum stillbirths).

On the right of the graphic is the type of mortality studied:

• PNM/NNM: intrapartum deaths + neonatal deaths up to 28 days
• PNM: intrapartum deaths + neonatal deaths up to 7 days
• NNM: infant deaths through 28 days; intrapartum stillbirths excluded

For Vlemmix, Vistad, Hartnack-Tharin, and Vistad, I included only the data from the later time periods (usually post-TBT).

The next slide shows the same dataset, adding in planned cephalic births (vaginal & cesarean)  analyzed in two of the registry studies.

The last slide shows the relative samples sizes of the various studies. On the right side, you can see the sample sizes of the pVBB and pCS groups.

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Is vaginal breech birth safe? Jan 24 webinar

On January 24, I will be giving a webinar about term breech: Is vaginal breech birth safe? Come join me!

This presentation reviews research on term breech that has emerged since the 2000 Term Breech Trial. From a PubMed search of “breech” and “pelvic presentation” in the title & abstract, I extracted over 1,900 articles published between 2000-2017.

I examine the evidence on term breech broken into several categories: neonatal morbidity, perinatal/neonatal mortality, long-term childhood outcomes (1-18 years old), short-term maternal morbidity, maternal mortality, long-term maternal outcomes, and outcomes for the mother’s future babies. I examine where the evidence falls for term breech in developed versus developing countries and for breech birth at home. I present research updates on other relevant topics, such as upright breech birth and the role of maternal positioning in altering the dimensions of the pelvis. I also discuss how vaginal breech skills help make cesarean sections safer for head-down babies that are deeply wedged in the maternal pelvis.

I finally put all of the evidence together—short- and long-term for both mother and child and the mother’s future babies—and demonstrate the complex risk calculus involved in answering the question, “Is vaginal breech birth safe?”

Time: Jan 24 at 3 pm EST (12 pm PST, 9 pm in Western Europe) or listen later to the recording
Cost: $30
Duration: approx 90-120 minutes, including time for Q&A

If you can't listen live, you will also be able to access the recording. Please register today!

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Indie Birth podcast on my breech research and my birth stories

I recently did a podcast with Maryn Green of Indie Birth: Restoring women's choice for vaginal breech birth: My chat with researcher Dr. Rixa Freeze.

In the first half, I talk about all of the breech-related research projects I'm working on. And then I tell my four birth stories. Come listen!

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We need your letters to support vaginal breech birth!

Dr. Annette Fineberg, an OB at Sutter Davis Hospital, has requested letters of support from women who have had breech babies. She is experienced in vaginal breech birth but has encountered significant roadblocks from her hospital. She has also been unable to get privileges at a nearby tertiary hospital to do breeches there.

Please write letters of support for keeping the option of vaginal breech birth available! More details below from the OB:

I need to ask a favor from anyone who

1) had a vaginal breech birth in the hospital,
2) had one at home because that was your only option, or
3) was pressured into a cesarean because it was not an option due to hospital policy or lack of experience of attendant

I am getting a lot of pressure to stop attending breech and despite my best efforts to get privileges at a tertiary care hospital with neonatology, it is not happening.

Please send your impassioned pleas and experiences to:

Sutter Davis Hospital Birth Center
2000 Sutter Pl
Davis CA 95616 

Thanks!

[And please also send me a copy of your letter so I can forward it on to the OB!]

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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.

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.

Leung, Pun, and Wong (1999) mention performing IP ECV on 5 out of 28 undiagnosed breeches in early labor, of which 2 turned successfully and both ended in vaginal births.

Belfort (1993) includes a case report of a multiparous woman presenting in labor with an unengaged complete breech with both feet palpable through the intact membranes. When she was 5 cm and 70% effaced, an IP ECV was performed in the delivery room with IV nitroglycerin. The procedure was successful. The woman received amniotomy and oxytocin to restart contractions and had an uneventful vaginal birth 8 hours later.

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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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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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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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