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Thursday, November 29, 2007

A simple breech birth criteria

Last spring, I had the pleasure of meeting Dr. Mayer Eisenstein, a physician who has attended home births in the Chicago area for several decades with HomeFirst. He worked with Dr. Gregory White, also with HomeFirst and author of the manual Emergency Childbirth used by police officers and EMTs.

While we were talking, Dr. Eisenstein told me of a simple criteria for predicting whether or not a vaginal breech birth will develop difficulties. He learned this when he was a young physician from Dr. Frank O’Connell, who was a senior obstetrician at St. Francis Hospital in Evanston, IL. Dr. O’Connell learned it from his father, also an obstetrician, who had worked as the Chair of Obstetrics starting in the late 1950s or early 1960s.

Rule #1: If the presenting part is at a positive station at 5 centimeters dilation, there is an overwhelming probability of an easy birth, irrespective of what part is presenting (foot, knee, butt) and irrespective of parity. In other words, it is just as true for primips as for multips, just as true for footling breeches as for frank (butt-first) breeches.

Rule #2: If the presenting part is at negative station at 5 centimeters dilation, there is a significantly higher probability of a difficult birth, irrespective of the presenting part or of parity.

These criteria are more accurate in predicting easy births than in predicting difficult ones. In other words, a women may still have a straightforward birth when the presenting part is at negative station, but it is just much more likely that difficulties will arise.

Dr. Eisenstein and some of his medical students reviewed over a decade of their records to see if this held up with the breeches they had attended. In over 100 breech births they had attended, the rule held true in all the cases.

Dr. Eisenstein added that it should be blatantly obvious at 5 centimeters that the presenting part is at positive station (this does not include zero station, only true positive station). No guessing.

Dr. O’Connell’s father also had another rule: “The sign of a good obstetrician is how few cesarean sections they do.” I like that one!

23 comments:

  1. Wow! I like that criteria for a good OB, too.

    I find it fascinating that something as straight-forward as this criteria could be used to take breech births out of the realm of the operating room, and put them back into the labor/delivery room where they belong. Is there some way that this criteria can actually find its way back into mainstream obstetrics?

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  2. you know, I don't care much for him at all (god, I really don't like him), but some of this makes sense, but overall the key here is that none of this criteria ensures a safe outcome or complications.

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  3. I find these criteria interesting, because most breech criteria are a lot more concerned with parity and presenting part. This has more to do with the dynamics of the individaul woman's labor. I wonder how much of this corresponds with Michel Odent's approach to breech: if everything is progressing smoothly, if labor is getting stronger and moving along, then generally all will be well with the breech. If, on the other hand, labor stops and starts a lot, then there might be reason to be more concerned. More about it in "Birth Reborn."

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  4. But what do they plan to do once they've 'predicted' a difficult birth and got concerned? Let the profecy fulfill itself? Isn't this more information of the ultimately pointless kind? At best pointless but possibly even harmful? (Kind of like all those vaginal exams they had to perform on 100 women to get to this generalization...)

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  5. True enough Judit. I think the information is only useful in that when a woman does have a positive station, the attendants can be pretty much sure all will go well and just relax...the trouble is with the other situation since it doesn't mean there will be trouble, just that it is more likely.

    This is the kind of thing that, as a birth attendant or as a pregnant mother, I'd file away in my brain but not revolve my entire decision-making process around.

    Anyway breech is such an interesting thing. It has so many cultural layers of meaning to it now, mostly ones that involve lots and lots of fear.

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  6. ...but then again, in the real world... like Kelley commented: if this were to become an ACOG recommended protocol saving women from an automatic section for term breech, instead letting them have a trial of labor to 5 cm, it many mothers might be spared from cesareans, most importantly primary cesareans!! Vaginal breech would go from impossible to possible but hard to obtain, I guess just about like a VBAC. It might increase the choices for some breech mamas.

    Back to my usual dreamy idealism: imagine, breech home birth might get less stigmatized, too! I'm sure my midwife and I would have worked something out back when M was breech, rather than her having to threaten me with abandonment. (Good thing I didn't/don't take it personally, but that really really reallly sucked.)

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  7. Did Dr. Eisenstein publish his findings? I'd love to read them firsthand.

    Thanks, Maryanne

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  8. I asked him if he'd ever written up his findings, and he hadn't. So I thought I would at least report them here so people know about this.

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  9. Judit,

    I just want to say that, fwiw, as a mom who had a breech vaginal birth in March 06, I did have frequent vaginal exams, and believe it or not, they didn't bother me.

    TBH, it may very well have been that I had no other breech birth options, so if that's what it took, but I don't think so.

    I did tons of breech birth research, having had the "advantage" of having had two cesareans for breech, so knowing that breech might be a possibility if not probability, and I knew that lack of progression, either in dilation or descent was a concern in breech birth. For this reason, I believe, the vag. exams were comforting in some ways (though not comfortable of course).

    Just my perspective fwiw.

    Hope you are well, as I said, it was nice to see your name pop up.

    Christie, NY
    3 kids/2 c/s from my septate uterus
    One amazing breech HBA2C 3/06

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  10. That's too bad-- without the data from his study being published, it is hard to scrutinize the data to make sure the conclusions are justified. OB's, and perhaps midwives, are less likely to change their practices without it-- and that's too bad, because obstetrical care obviously could use a lot of change.

    Maryanne

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  11. Yes, it's too bad it only exists on the level of anecdote and practical experience. (Thing is, so does much of obstetrics and midwifery). But it's important to know these things, so that hopefully at some future point we can evaluate whether or not they hold up in a research setting. Even a prospective study of this would be interesting, assuming patient records are accurate enough. Problem is, we have so few vaginal breeches that it would be hard to get information. And I wouldn't personally trust data from breech births that were induced, augmented, or anesthetized. From birth attendants who have experience in true "breech births' (compared to breech "deliveries" or "extractions"--see Mary Cronk's writing on this) they say it's imperative not to do anything to hasten the labor or to interfere with the mother's ability to push.

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  12. That criterion doesn't make much sense. If the presenting part has descended by 5 cm, that means that the presenting part is likely to deliver. However, the most dreaded complication of a vaginal breech is a trapped head, in other words: the presenting part delivers, but the head gets stuck. Whether or not the presenting part fits tells you nothing about whether the head will fit.

    It's not suprising that these criteria were not published. They make no sense.

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  13. Dr Amy,

    How often is it that babies' heads honestly don't fit through their mothers' pelvises? Seriously? I know we hear a lot about CPD, but how often, when the mother is able and willing to move around and work her baby down, is it that the head honestly doesn't fit? I don't see why a trapped head would be any more of an issue when the baby is right side-up than when upside-down.

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  14. Kelley:

    "I don't see why a trapped head would be any more of an issue when the baby is right side-up than when upside-down."

    It is a very serious problem because the head is the largest part of the baby's body. Approximately 96% of babies are head first at the time that labor begins. Since the head is the largest part, if the head can negotiate the pelvis, the rest of the body will easily follow. The only exception is in the case of shoulder dystocia.

    Moreover, the skull has plates that are not yet fused and can overlap one another. This is what is known as "molding". Molding actually decreases the diameter of the baby's head, allowing it to pass through the pelvis more easily.

    In the case of breech, the body is born first. It is possible for the body to fit and the head to become trapped. The umbilical cord is exposed to air when the baby's body is delivered and usually goes into spasm. Therefore, the baby begins to suffocate if the head is not delivered within a few minutes.

    If the head comes after the body, it cannot mold to fit better and there is not enough time for it to mold before the baby dies.

    The studies of vaginal breech birth, in which the only babies that were delivered breech were those who met strict criteria (frank breech, flexed head, etc.) and which were attended by very experienced obstetricians and full neonatal resuscitation teams had a neonatal death rate of approximately 8 per 1000. In contrast, breech babies in the same study delivered by C-section had a mortality rate of 2 per 1000. That doesn't sound like much, but if breech babies in the US were routinely delivered vaginally, we would expect approximately 480 additional preventable neonatal deaths each year.

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  15. in a full term frank breech baby, the likelihood of head entrapment is very, very rare. You have not only the bum but also the legs up along the trunk dilating the cervix. This usually results in the same dilation - if not a bit more - than is necessary for the head. We also know that there is some molding of the head that occurs with the fundal pressure as baby descends.

    I think that head entrapment is much more of an issue for preterm babies - those babies whose heads are larger in proportion to their bodies simply because of gestational age.

    Head entrapment is such a weird argument against full-term frank breech babies. It physiologically doesn't make sense.

    The biggest risk with most vaginal breech birth is the provider manually manipulating the baby out when the body is born. This manual rotation of the head - either with hands or forceps - puts the most pressure on the head and results in the biggest injury.

    So, yes, if my only choice for breech birth was an inexperienced, scared doc, I'd take a cesarean. If I was in the hands of a provider that knew enough about the benefits of upright delivery, hands off the breech, etc., then I'd feel much better.

    IMO, so much of the danger with breech really depends on the fear and intervention of the provider.

    (and nobody said that this was a study - it was one docs observations. I think much of medicine and midwifery works like this - anecdotal info is good for sharing, but it should never be the thing that drives pratice)

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  16. "I don't see why a trapped head would be any more of an issue when the baby is right side-up than when upside-down."

    "It is a very serious problem because the head is the largest part of the baby's body."

    Actually, the difference btwn the circumference of the head and the buttocks at term is quite small. You know, imo, and I've researched this *a lot* having had 3/3 breech babies, if a careprovider has fear, that is the most important risk.

    IMO, Breech is a variation of normal (course, ime, it is normal :-) As Pamela said, with a competent careprovider, the poor outcomes for breech babies are not seen as the debunking of the Hannah Breech Trials demonstrates.

    "Approximately 96% of babies are head first at the time that labor begins. Since the head is the largest part, if the head can negotiate the pelvis, the rest of the body will easily follow."

    Yet, as you mention, SD is a risk and we don't section every mom for the possibility of SD. And remember, c/s are not without risks to the mom or baby. Babies have a significantly higher incidence of breathing difficulties, and there are new study results which suggest that neonatal death is higher in c/s born babies.

    "Moreover, the skull has plates that are not yet fused and can overlap one another. This is what is known as "molding". Molding actually decreases the diameter of the baby's head, allowing it to pass through the pelvis more easily."

    I've done *tons* of reading on this, and I've never seen this stated, but from my son's birth, it seems to me that his body provided the leverage to straighten and ease out the head and therefore molding is not issue.

    "In the case of breech, the body is born first. It is possible for the body to fit and the head to become trapped."

    Possible but unlikely. This statement reflects the belief that true CPD is not a rare event which it is. Our bodies do not grow babies that they cannot birth with a few exceptions.

    "The umbilical cord is exposed to air when the baby's body is delivered and usually goes into spasm. Therefore, the baby begins to suffocate if the head is not delivered within a few minutes."

    If the umbilical cord is kept covered and warm, the spasm is not likely to happen.

    "If the head comes after the body, it cannot mold to fit better and there is not enough time for it to mold before the baby dies."

    I'm sorry you are so afraid of breech babies. See my earlier comment about molding.

    "The studies of vaginal breech birth, in which the only babies that were delivered breech were those who met strict criteria (frank breech, flexed head, etc.) and which were attended by very experienced obstetricians and full neonatal resuscitation teams had a neonatal death rate of approximately 8 per 1000. In contrast, breech babies in the same study delivered by C-section had a mortality rate of 2 per 1000. That doesn't sound like much, but if breech babies in the US were routinely delivered vaginally, we would expect approximately 480 additional preventable neonatal deaths each year."

    I don't have the studies handy, but I do have a list of breech references that I'd be happy to post. If these numbers come from Hannah, which I believe they do, that research has been debunked.

    But again, I agree that sig. risks exist when an inexperienced and fearful attendant is involved.

    12/1/07 9:20 PM

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  17. Pamela:

    "in a full term frank breech baby, the likelihood of head entrapment is very, very rare."

    I'm not sure what you mean by "rare". Perhaps an excess rate of preventable neonatal death seems "rare" to you; after all, it's 0.6%. In this country, where there are approximately 4 million births per year, it represents the death of about 480 neonates.

    You can also look at the homebirth studies. In virtually every homebirth study that included breech, a significant proportion of the breech babies died.

    There is currently a story running in the British papers of a midwife who is being investigated because of a breech homebirth death due to a trapped head.

    In September, the Oregon Register Guardian ran a story on the homebirth death of a breech baby with a trapped head.

    Over at MotheringdotCommune, you can read the stories of at least 10 easily preventable homebirth deaths in the last two years, including a trapped breech.

    Whether you think an additional 6 per 1000 deaths of breech babies per year is a lot or a little, the key point is that breech quadruples the risk of neonatal death of low risk babies, and that these deaths occur quite regularly at homebirth attempts to deliver breech babies.

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  18. http://www.lamaze.org/Research/WhenResearchisFlawed/VaginalBreechBirth/tabid/167/Default.aspx

    I only had a moment to skim, so I'm not sure if she has the M & M numbers in here, but take a look

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  19. Amy addressing Pamela:

    Pamela:

    "in a full term frank breech baby, the likelihood of head entrapment is very, very rare."

    "I'm not sure what you mean by "rare". Perhaps an excess rate of preventable neonatal death seems "rare" to you; after all, it's 0.6%. In this country, where there are approximately 4 million births per year, it represents the death of about 480 neonates. "

    ******Citation?**********

    "You can also look at the homebirth studies. In virtually every homebirth study that included breech, a significant proportion of the breech babies died."

    ****Citation?*****

    "There is currently a story running in the British papers of a midwife who is being investigated because of a breech homebirth death due to a trapped head.

    In September, the Oregon Register Guardian ran a story on the homebirth death of a breech baby with a trapped head."

    Yes, breech babies die. So do vertex babies and moms from cesarean surgery. We've had two such deaths of mothers here in NY in the past few months. The mother most local to me, died from a clearly preventable cesarean for "Failure to Progress". The challenge is for the *parents* to balance the risks and make an informed decision.

    "Over at MotheringdotCommune, you can read the stories of at least 10 easily preventable homebirth deaths in the last two years, including a trapped breech."

    Yes, and I'm sure on the OB forums, you could read of many preventable deaths as well. I'm always fascinated by the belief in our culture that in birth, risk comparisions are akin to comparing an apples and oranges(in other words, no/little risk to risk). It simply isn't so.

    "Whether you think an additional 6 per 1000 deaths of breech babies per year is a lot or a little, the key point is that breech quadruples the risk of neonatal death of low risk babies, and that these deaths occur quite regularly at homebirth attempts to deliver breech babies."

    Again, I would like the citations. I'm also curious as to how homebirth came into the discussion. If it is a recognition that very few OBs in this country possess the skills to attend a breech vaginal birth, then it makes sense to me.

    Furthermore, a point sorely lacking in your assessment, is that even cesareans for breech carry similiar risk. The same gentle maneuvers required for a baby to be born vaginally are required when delivered by cesarean. Again, not a risk vs. no/little risk scenario as it seems you paint.

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  20. Whenever "Doctor Amy" comes onto anyones blog, it is always a total bummer. Not only does true conversation seem to shut down, but noone else feels comfortable discussing anything else but her ideas. Yay.

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  21. Okay, so let's lay aside the debate over vaginal vs cesarean statistics and the issue of how often head entrapment really develops...

    More important issues at hand:
    - loss of skills in vaginal breech births
    - erosion of choice--breech in almost all areas is an automatic cesarean. How does this affect women's right to informed consent (which implies a right to informed refusal, but basically if your only options are cesarean, how can you refuse?)
    - problems in studying breech outcomes (differences in caregiver skill, interventions during labor, etc that all may affect outcomes)
    - breech births (baby is born with no outside interference, "hands off the breech") vs breech extractions (the way they're usually done in hospital)
    - cultural fear of breech: how/when did it develop, are fears appropriate to the level of risk?

    Oh, I meant to say "even a retrospective study would be interesting" a while back. I mean, if we don't ask questions we'll never know the answers, right? There is so much we do not know; hence this post.

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  22. Thank you Rixa!

    (But before we get back on track: the thought of dr Amy poking around on MDC for tragic birth outcomes makes my skin crawl. This must be what anonymous means by 'bummer':) The dead baby scenarios and anecdotes introduce extremes of the language and (il)logic of risk.

    Risk assesment does not dictate choice.

    We will eventually need to have a big meta-discussion about the ethics of parents making decisions where comparing various risks to mother and baby is indeed like comparing apples and oranges. It's easy if you believe this: Hey, hands off breech is just as safe, so do what you want. It's harder to say: We don't really know for sure what will happen, but still, do what you want. The latter is what I want to hear.

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  23. I just think it is hilarious for any doctor from this country to say that it is so neccesary for breech babies to be birthed by cesearean when it is such a well known fact that, for a developed country this country has the highest cesarean rate and one of the worst mother AND infoant mortality rates. All over Europe breechs are delivered vaginally successfully. And more babies are living over there.

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