Friday, July 29, 2016

Cabin fun

I've been traveling for the past two weeks and haven't had internet access for the past week. Here's what we've been doing:

Once I get back home, I'll keep adding summaries of the First Amsterdam Breech Conference.
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Sunday, July 17, 2016

Update about Nice

I've received so many messages from people wondering if we're okay after the attack on Bastille Day in Nice. Thankfully, yes, we are fine. We didn't go the fireworks that night because we were getting up at 4 am the next morning to fly home. Around 11 pm, Eric was looking out our windows and saw people running down the streets in a panic. We knew that something was happening, but had no idea of the specifics. When we went to bed after midnight, there were vague reports of a vehicle on the Promenade, but it wasn't clear if it was an accident or not.

Our phone starting ringing at 2 am with family members asking if we were okay. We wondered what all the fuss was about and got progressively grumpier with each phone call. Finally we got out of bed to see what had happened. Just terrible.

I go walking along that stretch of the Promenade every evening. The police stopped the truck about 500 meters away from where we usually watch the fireworks. If we had gone that night and if it had taken just a bit longer to stop the driver, we would have been right in his path.

When we left Nice, the entire Promenade was closed down from the Old Town to the airport. The Jazz Festival was cancelled. Rihanna cancelled her concert scheduled for the 15th.

We spent two days getting home due to flight cancellations and finally arrived yesterday evening.
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Sunday, July 10, 2016

Floortje Vlemmix: Shared Decision Making and Term Breech in the Netherlands

First Amsterdam Breech Conference, Day 1
Floortje Vlemmix 
Shared Decision Making and Term Breech in the Netherlands

Floortje Vlemmix, MD PhD, is a resident OB/GYN at Academic Medical Center in Amsterdam. She wrote her PhD thesis about breech birth in 2008. Her presentation focused on two main topics: shared decision making and the risks of vaginal breech birth. She noted that some of her physician colleagues feel that shared decision making is a farce; it's really just doctors telling women what they should do. But Floortje believes in it.She defines the term as something that "enables you to guide women in their decision on breech delivery."

When she speaks to women about breech birth, she gives them information and asks them to come back and tell her what they'd like. She starts walking them through the risks and benefits. She has to ask herself, "Have I really listened to the patient? Do I know her fears, her desires? Maybe she agreed to the cesarean just because that’s what everyone has been telling her."

Floortje discussed how obstetrics is all about preventing perinatal morality and morbidity. Obstetricians need to identify who's at risk, have a diagnosis, and then propose a treatment to prevent the risks. For breech babies, this is crystal clear. We can see if the baby is breech via ultrasound. There's enough evidence to know what the risks are. Citing articles by Thorton 2015 and Vlemmix 2014, she argued that an emergency cesarean is the worst outcome for a breech.

Floortje then posed a question: knowing the data on term breech, is there really a choice. Her conclusion, if you don't take into account subsequent pregnancies, was no. Cesarean section is preferable. See Berhan's 2015 meta-analysis. For example, the perinatal mortality rate for planned vaginal breech is 1.6/1000 compared with 0.5/1000 for planned cesarean section. However, if you include future pregnancies, the planned vaginal cohort had a mortality rate (for the birth after their breech baby) of 1.3/1000, compared with 2.5/1000 with the planned cesarean cohort.

Only two qualitative studies exist about breech birth: one from Switzerland and one from Australia.

Next, Floortje presented Glyn Elwyn's model for shared decision making in clinical practice (2012).

She noted that three decision-making tools for women in the Netherlands are in the works. She called for more decision aid tools tailored to individual women and hospitals. We may not avoid every complication, but we need to try our best to minimize them given the women's decisions.

Comment from Betty-Anne Daviss: In Canada, sometimes we tend to head towards evidence-based medicine, assuming that evidence-based = science. Some cultures or people don’t look at science the same way. The Inuit, for example, highly value staying within their communities, so in Canada there are lots of other parameters besides scientific parameters that pregnant women take into account. Science is only one part of the decision-making. And none of those studies that you cited had upright positioning for the vaginal breech births.

Rixa's commentary: Floortje's presentation was a counterpoint to the rest of the conference with her perspective that cesarean section is clearly preferable to planned vaginal breech birth. I was glad that she presented and was willing to enter into a dialogue with people who might not agree with her conclusions. Let's continue to come together and learn from each other!
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Saturday, July 09, 2016

Rebekka Visser: Guidelines and Realities, Dreams and Controversies

First International Breech Conference, Day 1
Rebekka Visser
Guidelines and Realities, Dreams and Controversies

A Dutch midwife from Usquert, Rebekka Visser is an advocate for women who want hands-off, self-directed breech births. Her midwifery practice is called Springtij.

In lieu of posting a summary of Rebekka's remarks, I will direct you to her blog, where she posted her presentation: "Let's Look Beyond Our Fishbowl."

At the end of Rebekka's lecture, an audience member asked other attendees about how breech skills are taught in their locations. Is breech taught as an emergency procedure? Or is it taught as a normal birth skill?

We had responses from many other audience members. I remember hearing someone comment that when breech is taught as an emergency skill, the rate of vaginal breech birth in a maternity unit actually goes down. This emphasizes the importance of teaching breech as part of normal birth skills, rather than labeling it as an "emergency."
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Thursday, July 07, 2016

Irene de Graaf: Risk, Rules, and Reality

First Amsterdam Breech Conference, Day 1
Irene de Graaf
Risk, Rules, and Reality

Irene de Graaf, MD PhD, is a neonatologist who focuses on shared decision-making and who works with women who go outside of the expected medical protocols. In her presentation, shared her thoughts on breech birth and the reality of her daily practice.

Together with a midwife, doula, and obstetrician, Irene runs an outpatient clinic offering tailor-made care in obstetrics. It is called Poli Ondersteuning Maatwerk zwangerschap & geboorte (POM). This includes women who wish for medical interventions outside established guidelines as well as women who want a natural birth outside those guidelines. She sees women who want no fetal monitoring during labor, who want to birth in a vertical position, and who want to be supported by their own midwife at home. She also sees women planning cesarean sections who want to to wait until labor begins before having the surgery.

Irene referenced a 2015 meta-analysis about the risks of planned vaginal versus cesarean birth for term breech babies. She also referred to both the Dutch and RCOG guidelines for breech babies. In her clinic, they do not force any guidelines on the women they care for. Her experiences working with women outside the borders of normal medical practice sparked several questions:

1. Why do women want care outside the normal guidelines?

  • Fear of cascade of interventions
  • Fear of being treated as number, as a victim of protocols
  • Fear of losing autonomy
  • Strong belief in their own strength and intuition

2. Why do doctors not want to make exceptions to breech guidelines?

  • Fear of being responsible if guidelines aren’t followed
  • Fear of breech birth
  • Strong belief in numbers
  • Desire to rule out every (small) risk
  • More confident in doing things they can control

3. “If we want, we can.” We have to be response-able—able to respond to different situations.

4. Why can’t we solve this issue? Irene identified several practical solutions:

  • Centralizing breech services would focus breeches in one location and give providers more experience
  • Train practitioners
  • Open your clinics so that others can watch & learn breech skills
  • Listen to the expectations of pregnant women
  • Support women's decision making

For answers to more of these questions, she suggested that we "ask the midwife!"--specifically, Dutch midwife Rebekka Visser, who was the next speaker.
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Wednesday, July 06, 2016

Gail Tully: Visualizing (Obstructed) Breech Birth

First Amsterdam Breech Conference, Day 1
Gail Tully
Visualizing (Obstructed) Breech Birth:
Breech Complications Illustrated, 
Particularly Trouble with Rotation or Flexion

Gail Tully, CPM, BSc, is a midwife from Minnesota and founder of Spinning Babies. Her session focused on tricky breech situations, and it kept us all on the edge of our seats. It felt like we were all collectively holding our breath! She showed us videos of situations she has encountered that were far from "textbook."

Gail noted that she is an observer; she figures out what’s going on inside by observing what’s going on outside. The mother's soft tissues are very important, as they determine the baby’s rotation. Ligaments can affect a baby’s lie, and sometimes they twist the uterus. Any amount of torsion reduces the space for the baby’s head and perhaps makes it more adaptable for a baby’s bottom (a theoretical explanation of why some babies are breech).

Soft tissues matter and, in many cases, determine the baby’s position. Myofascial therapy and pelvic alignment may improve safety. Gail mentioned an OB/midwife team doing myofascial release before ECV; often the baby is head-down at the ECV appointment, or there is less resistance during the ECV.

Words of advice for working with breech babies
Another way to protect the journey is to collaborate with a team, where midwives work together with doctors. And good nutrition, of course! She advised providers to assess and chart carefully. Track how the breech baby is doing during labor and pushing.

You don’t always see a color change in the breech baby—especially in a water birth—until some other sign indicates the baby is not doing well. Be aware that a placenta can detach before the baby’s head is out.

The breech is a wonderful dilator of the cervix and the perineum.

As the presenting part comes onto the perineum, help the mother retain her confidence and calm. Some women will naturally resist those sensations. Use Ina May’s suggestion and say, “You’re going to get this big” while making a nice wide circle with your hands.

3 pillars of safe breech birth:
1. Hands and knees (upright)
2. Hands off the breech--unless the baby needs help, as indicated by its tone or position!
3. Don’t clamp the cord!

When to be hands-on:
When baby appears deflated, hollow, or limp. Kristeller (fundal pressure) might be advisable in this situation.

Gail comes from a midwifery background that highly values patience, mothers' instincts, and babies taking their time. However, she said that we can’t use a lack of understanding as an excuse for "patience." Our neglect can’t be ideologically justified; we must understand when the baby looks good or not.

What we see on the outside tells us what’s going on in the inside. 
Be observant. Look at how the baby is appearing on the perineum and how it’s rotating.

Normal: The baby’s abdomen is to the mother’s anus when torso and arms are being born. Then baby’s shoulders shift slightly to the oblique to release the arms.

Not normal: The shoulders stop in the AP diameter. You can have either unilateral or bilateral nuchal arms. The baby's spine stays facing the mother’s thigh and progress stops. Sometimes an arm/shoulder gets stuck inside the symphysis pubis (less common—she’s seen it twice).

In this illustration, the baby on the left is emerging normally; the baby on the right will need help. (Mother on hands & knees)

Illustration by Frank Louwen

To release an arm, the baby points the way. 
When the baby's spine is facing the mom’s thigh, imagine the baby pointing behind its head.

If the baby is lively, wait another contraction to see if an arm emerges. (This applies only to the posterior arm, the anterior arm will not come down on its own.) If not, reach up around baby’s chest and rotate in the way the baby is pointing (rotate a full 180 degrees). Then once that arm emerges, rotate 90 the other direction to free the other arm. You want to end up with the baby facing the mother’s anus.

Sometimes baby’s arms are over the head. 
The spine will look like it’s lined up correctly, but you won't see the full abdomen and possibly not even the umbilical cord.

Baby might attempt a tummy crunch to get the arms into the pelvis, or to get the next body part into the pelvis.

After this flexion reflect, expect to see action. If there’s no descent, then it’s your sign to take action.

When baby’s head is stuck: 
First you must know what normal looks like for the birth of the head. For an upright breech birth, you will notice:
  • Head flexion
  • Perhaps a bit of chin or face emerging from the perineum
  • Full perineum
  • Mother's anus is open

You might need to move the chair/ball/bed/husband away from under the mom so she can bend down towards the floor. If the baby is limp and nothing is happening, you can ask to move the furniture.

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.

During her presentation, Gail showed us another way to flex and free the head by pressing on the hollow space underneath the clavicle, near the shoulder. Gail made a video in conjunction with massage therapist Adrienne C. Caldwell explaining the muscles and ligaments involved in the shoulder press. I was fascinated to learn the mechanisms by which pressing on the subclavicular space presses flexes the baby's head.

In an email correspondence after the conference, Gail clarified:
I don't suggest the shoulder press. I acknowledged that there are two variations, but I am promoting the one Adrienne describes which I named the SAFE way to free the breech head: Subclavicularly Activated Flexion and Emergence. This is a major point with my talk; that's why I made a film of Adrienne explaining the technique....[Pressing on the subclavicular space] is how Frank first explained it, but he moved towards a mechanical way of working with this and so does Anke. I have just tapped the hollow spot and gotten flexion immediately without the added mechanical push.
With either variation, press straight back towards the mother's pubic bone. Don't press down!

Finger flexion technique: The baby's head is released by placing your fingers on the temporal bones, then gently flexing the head.

Stargazer babies: Reach up to the chin, slightly turn the baby's head to the oblique to bring the head down, then turn the baby's head back to the AP diameter.

If you know the principles, you can adapt to whatever position the mother is in. Mothers often rapidly change positions. When the mother is on her back, you want to see the nape of the baby's neck.

Breech and birth pools
It can be hard to make adaptations in the birth pool. Or if the mother is crouched way too far down, almost sitting on top of her heels with her torso to the floor, it can close her pelvis a bit. When women are on all-fours in the birthing pool, their thighs are flexed in varying degrees, all of which slightly or notably close the inlet (see articles by Desbriere, Guittier, and Reitter). Gail is not favorable for water births for breeches, generally. She believes that being in the water closes the AP inlet. Gravity can help bring the baby down more quickly when the mother is on land. In a post-conference email correspondence, Gail added:
When babies come quickly, water birth can be best, but when a breech is stuck, it is not desirable to have mother move so significantly as to get out of the pool with the baby's body out and head remaining inside. To open the pelvis optimally for a breech baby's head, the thighs need to move away from the abdomen, which would put a woman's head under the water!

In Sum
Frank Louwen taught us to have a formula ready for what could happen in an obstructed breech birth and to rehearse it several times in your mind. Then when the baby doesn’t go by the formula, you can figure out what’s going on and make appropriate corrections.

Comment from an attendee: If you can’t move the baby, move the mother.
A: Yes, even just getting her upright at a different angle can help.
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Three Perspectives on External Cephalic Version

First Amsterdam Breech Conference, Day 1
Three Perspectives on External Cephalic Version (ECV)

Marjolein Kok
Turn That Breech!: Important Aspects Of ECV

An obstetrician at the Academic Medical Center in Amsterdam, Marjolein Kok MD, PhD noted that in the Netherlands, there are about 6,000 breech babies born per year, of which 4,800 are born via cesarean and 1,200 vaginally. In the US, fetal malpresentation is the third most common reason for cesarean section. Her goal is to prevent all breech deliveries by turning the babies beforehand. However, she noted that this might be an impossible goal, as ECV has a 40-60% success rate. Still, ECV significantly lowers the overall cesarean rate for breech presentation by almost half. Of utmost importance for a successful ECV are an experienced operator and tocolysis.

She presented a list of favorable conditions for ECV, with the most important on top. A relaxed uterus is by far the most favorable factor, followed by an unengaged breech and a palpable head.

The rest of her presentation overviewed the literature on ECV from several angles:

Safety:  A 2008 meta-analysis by Grootscholten et al (PDF here) found that serious complications occur in less than 1% of ECV.

Eligibility: There is very little consensus on contraindications for ECV. In the five national guidelines surveyed in the above meta-analysis, there were 18 total contraindications, but only one was shared between all five guidelines: oligohydramnios. In addition, no contraindications in the literature were evidence-based, thus leaving only level III evidence (expert opinion) to guide decision-making. Her own level III recommendations for contraindications are:
  • History of placental abruption
  • Signs of placental abruption in current pregnancy
  • Severe preeclampsia or HELLP syndrome
  • Signs of fetal distress

Timing: She presented evidence from a Canadian RCT comparing early and late ECV. The data points to late ECV  (after 36 weeks) as being preferable and more cost-effective than early ECV (34-36 weeks).

How? When Marjolein Kok performs ECV, she follows the following procedures:
  • CTG to determine fetal-wellbeing
  • Ultrasound to determine presentation
  • Examination
  • Ultrasound gel (she feels it helps the operator's hands glide smoothly)
  • 2 operators (I didn't write down her reason for having two people present)
  • Tocolysis
  • Head roll
  • Anti-D immunoglobulin for Rh- women

Results: Marjolein noted that women with successful ECVS are still at higher risk for cesarean section compared to women with spontaneous cephalic babies. One study by de Hundt et al (2014) found the rate to be twice as high. However, this is still an improvement over a 100% cesarean rate in places where vaginal breech birth is not offered.

Marjolein concluded that overall ECV is safe and effective. More women are eligible that one might think, and it should be offered to every eligible women. Unfortunately, it's still not as widely used as she'd hope, as noted in a study by Vlemmix et al (2010).

Question & Answer Session
Q: What is the evidence for doing CTG before or after ECV?
A: There’s no evidence for doing it, but I usually do it before to assess fetal condition. It’s debatable. After ECV, we know that about 6% of fetuses have abnormal CTGs (usually temporary).

Q: (OB from Sheffield) If breech is normal, why do we have to turn breech babies around? This is more of a rhetorical question since I do ECVs in my practice.
A: Many places in the world don’t offer vaginal breech birth, so this can help in places where that’s not an option.

Mary Sheridan
Evidence-Based Management Of ECV In the UK: Findings From The “Think Breech” study

Mary Sheridan RM, MSc, is the coordinator of the Think Breech project and is currently working on her PhD. She is also a Midwife/Lecturer at Guy’s and St. Thomas’ NHS Foundation Trust/King’s College London. In the UK, 16% of all cesareans are due to breech presentation, and there are between 25-30,000 breech babies per year. Her project aimed to see how well maternity units were following the 2010 guidelines (PDF here). She visited units where the evidence-based guidelines were well-implemented, determined what these units had in common, then brought those findings to a unit that needed to improve.

Only 31% of the units she surveyed kept adequate data about their maternity patients--one of many barriers to evidence-based managements. Other barriers included unit culture, poor communication systems, and competing priorities.

Joost Velzel
How To Improve the Effectiveness Of ECV

Joost Velzel is a MD/PhD candidate at Academic Medical Center in Amsterdam. He is interested in improving the effectiveness of ECV, with a special focus on which type of tocolysis is preferable. His primary aims are:

1. Clarify best practice for tocolysis
2. Newtork meta analysis
3. Routine implementation

As Marjolein Kok mentioned in her presentation, tocolysis is the most effective predictor of a successful ECV. But which kind works best? He summarized the 18 existing RCTs on tocolysis beginning in 1987. His own research group also conducted their own RCT on beta mimetics. (Rixa's note: I don't think either of these have been published yet; if anyone can update this information, please leave a comment!)

One problem with existing RCTs is that they compare only one or two types of tocolysis against a placebo. So perhaps A has been compared to B, and B to C. But A has never been compared with C, so how can you tell whether A is better than C?

A network meta-analysis permits researchers to compare treatment methods that have never been directly compared in individual studies. Joost noted that a NMA can be more conclusive and more refined and precise than single RCTs or non-networked meta-analyses. His research group's network meta-analysis on tocolysis (proposal from 2014) examined beta mimetics, calcium channel blockers, nitrates, and oxytocin receptor blockers, with placebos as the reference. They concluded that "beta mimetic is the only proven effective tocolytic agent."

Joost noted that tocolytics have common side effects, but most are transitory. Serious effects such as hypertension occur less than 2% of the time. Women are generally willing to take medication with side effects if increases the success rate of ECV.

He noted that in the Netherlands, midwives are not allowed to administer tocolysis directly; they must have a physician administer the tocolysis even if they are the one doing the ECV. His main goal is to reduce breech presentation at turn and to optimize fetal version.

Question & Answer Session
Q: Do you know anything about tocolysis for ECVs done in a home setting? I don't think it's been studied yet.
A: Yes, that would be a great topic for a RCT. We don’t have information on that yet.

Q: (OB from Los Angeles) My real goal is to help women achieve a vaginal birth. In Los Angeles, if ECV is unsuccessful, almost all women have a cesarean delivery. The success of ECV is very tightly linked to cesarean section. Did women in these studies have the option of a vaginal breech birth if the ECV was unsuccessful?
A: Yes, I think that vaginal breech birth was an option in these studies, but I am not sure.

Q: Was the context of the mother taken into account?
A: No—that's something for the next round of studies!

Q: What beta mimetic agent? Which route? How long did you wait before doing the ECV?
A: For my RCT we used atosiban (rather than fenoterol) intravenously. We waited 15 minutes before doing the ECV.

Q: (Obstetrician who does home births). I almost always use hypnosis for ECV. I have a medical hypnotherapist for the procedure. I would suggests this as a future object of study.
A: Yes—another RCT idea!
A from audience: There’s a paper on it in the literature—it’s published.

Rixa's note: I was able to find two papers on the topic. Note that the first one was co-authored with Anke Reitter and Frank Louwen:

Q: When ECV doesn’t work, could it be more due to the resistance of the abdominal muscles than the uterus?
A: Perhaps, I don’t know. div>
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Sunday, July 03, 2016

Betty-Anne Daviss: Cardinal Movements and Crowning Touch

First Amsterdam Breech Conference, Day 1
Betty-Anne Daviss, RM, MA
The Usually Reliable Cardinal Movements of the Vaginal Breech

After some introductory remarks, Canadian midwife and researcher Betty-Anne Daviss noted that the term cardinal movements is a bit of a misnomer, because there are more variations in the descent of a breech breech than of a vertex baby. She briefly reviewed the cardinal movements of a breech baby through the maternal pelvis, noting instances that indicate a vaginal breech birth will not happen or will be problematic. For example, if the baby stays right lateral and doesn’t descend, that probably means a vaginal birth won’t happen. Both the posterior or anterior arms can become caught in various locations: on or under the sacral promontory or on the symphysis pubis.

I won't summarize the cardinal movements here, so I suggest you visit Jane Evan's video demonstrating the cardinal movements of the breech baby (from the 2nd International Breech Conference in Washington, DC 2012).

The most fascinating part of Betty-Anne's lecture was a description (including videos and reconstructions using a doll and pelvis) of a technique she calls the "crowning touch." She attended a birth where the head became hyperextended after the arms were born. She went up inside the mother with one hand, all the way along the side of the baby's head to the parietal bone, and she was able to then flex the head and bring it down. She suggested trying first with the cheekbone, and if that doesn't work, you can go up further and try on the parietal bone.

She wondered why obstetricians in the past have not done this and theorized that perhaps their hands were too large. Her hypothesis is that hand size/width might be an important consideration for the birth attendant, and hands might be a better replacement for forceps. For midwives who are not trained or not allowed to use forceps, using one's hand is a way out of feeling like you *have* to have forceps.

She also noted that the Frankfurt team has never had to use forceps to date, nor Andrew Bisit's unit in Sydney. She has also never seen a cervix clamp down over the baby's head, because once the baby is descending, the head comes right out.

Tips & tricks

  • Follow what the women are doing. For example, at her first solo breech birth at her hospital (where she was able to do the birth on her own, rather than transferring care to an obstetrician), the woman was on H&K on the bed and not much progress happened until she got on the birth stool.
  • Traditional midwives taught her to have the laboring woman grab a rope, sit and squat. They noted that women would often spontaneously fall over onto hands & knees when the baby was breech or had a (cephalic) shoulder dystocia. 
  • When you’re doing Frank’s nudge (aka the shoulder press), be sure the baby's head is turned to the front, rather than facing to the side. 
  • She’s learning as much about resuscitation in Frankfurt as about breech birth. They bring the baby to the mother and wait, rather than cutting the cord and removing the baby. 

Question & Answer Session

Q: Hypothetical question: In order to flex the head, you described pulling the face down. Would it be possible to put a hand up the back and push the occiput back?
A: Yes, certainly, depending on where the baby is in the pelvis. Try one or the other. I haven't caused any tears with this technique.

Q: OB from Sheffield: I have used my hands twice to push on the occiput, but both times were with face presentations for vertex babies.

Q: Why don’t you describe this maneuver and get your name on it? (said jokingly)
A: I’m Canadian and I don’t like drawing attention to myself. I really like calling it the “crowning touch.” It’s the final thing you might have to do if it’s really needed.
Read more ...

Saturday, July 02, 2016

Dr. Frank Louwen: The Re-Invention of Vaginal Breech Birth

First Amsterdam Breech Conference, Day 1
Dr. Frank Louwen
The Re-Invention of Vaginal Breech Birth

Dr. Scheele introduced Dr. Frank Louwen by noting that Frank's lessons on all-fours breech birth changed his hospital's policies. He and his colleagues were in a “magic trance” after Frank visited their hospital.

If Dr. Louwen's work interests you, you might want to read my summary of Frank Louwen's and Anke Reitter's presentations at the 2nd International Breech Conference in Ottawa, Canada in 2009.

Now on to Dr. Louwen's presentation:

Dr. Louwen began by arguing that safety and maternal wishes are not in conflict with vaginal breech birth. Done properly, vaginal breech birth can reduce complications for mother and babies. Cesarean sections have complications for mothers, for future pregnancies, and for babies. The important questions are: “Is breech pathology or a variation of normal? What is normal in breech? What is pathology? Can we exclude higher risk breeches from vaginal birth? Can we include births that would go well vaginally? What is the influence of maternal position on outcomes?”

He noted that we don’t have a choice to debate about vaginal breech birth because women are coming in pushing with breeches. If you only have cesarean section as an option for surprise breeches, you will injure the mother and baby. We have to make vaginal breech birth safe. When a mother presents with a breech emerging, you need the skills to do a safe vaginal breech birth—not a cesarean!

Dr. Louwen mentioned that he loves cesareans—if he has a good indication for them. But they also have risks, including unexpected pediatric ones (see, for example, studies by Thavagnanam, Cardwell, and Almgren cited below). Do we have an indication for cesarean with breech babies? To answer this question, he noted that to do an intervention, you need an indication. And indications are related to pathology, not to normalcy.

He noted that Germans are really good at following the latest evidence in obstetric practice. So when the Hannah Term Breech Trial (TBT) came out, showing equivalent outcomes for the mother and benefits to the baby for planned cesarean, they believed the trial. But they didn’t look closely enough at the numbers. This led him to wonder if they should trust in those numbers, since the TBT outcomes were outrageous even among the planned cesarean group.

He noted that Glezerman’s response to the TBT explained what was wrong with the analysis of the TBT data. He also noted the changing recommendations for breech delivery in the 2000, 2001, and 2015 Cochrane systematic reviews. He also cited obstetric guidelines from around the world, all advising an experienced attendant for a safe vaginal breech birth. But around the world, people are losing this experience.

Dr. Louwen argued that we do a lot of unproven procedures in obstetrics. He wants to convince us that breech is normal, not pathological. We can prove this hypothesis: if something happens spontaneously and if an issue resolves itself without any help at all, then it is normal. If it needs help, it is pathology.

Why is Amsterdam the right place to talk about the breech from the German perspective? More than 80 years ago, a famous German obstetrician came to an international conference in Amsterdam about breech—Erich Bracht. From Bracht's experience in Berlin, he noticed that the less you touch the breech, the fewer the complications. That was revolutionary at the time. Until he gave that presentation in Amsterdam, every breech was extracted because of the influence of François Mauriceau. Bracht advocated the opposite: it was a revolution. The only maneuver is to move the baby around the symphisus of the mother as the torso and head are being born. See this illustration:

He next told the story of how he came to (re)discover upright breech birth. He was on a telephone call with Bracht’s book open to the above illustration. During the phone call, he walked to the opposite side of the desk. He glanced at the book during the phone call and saw this:

He didn’t recognize the pictures. He stopped the call immediately and looked again more closely. An idea came to mind: “What would happen if I turned the woman around?” It took several months to actually do a breech birth on hands & knees because he and his colleague Dr. Anke Reitter had to re-learn everything “upside down.”

His first upright breech birth was a primip. He told her about his new idea of having the woman upright, but he'd never actually done it before. She said, “Try it out. If it’s not working, then turn me around!” In the event that it worked, she insisted on having him show off her photos to audiences like ours!

What is normal? What is pathology? 
Frank Louwen noted the disparity between well-defined cesarean techniques and poorly defined vaginal breech births--one reason why studies comparing the two are subject to criticism. With cesareans, the techniques are described, codified, and clear. But with vaginal breech birth, we have many unanswered questions: could the woman walk? Take a bath? Did she have drugs? Oxytocin? Episiotomy? What position was mother in? Everything is well-described in the planned cesarean group, while you know almost nothing about planned vaginal group. That’s the big problem of Hannah trial: what exactly are we comparing in those two groups? What is the influence of the maternal position?

This led him to another question: Is upright positioning the intervention? Or is having a mother on her back the intervention?

He noted that women in his unit go onto the hands & knees position just when the buttocks of the child begin emerging. Before that, the women are free to walk around and do as they please. He never does episiotomies during a vaginal breech birth because the evidence points to rising complication rates.

An old saying goes: “If you deliver a breech baby, never look at the face of the child.” This was true for women birthing on their backs. However, if the women are turned around on her knees, the saying now goes: “If you deliver a breech baby, always look at the face of the child.”

Cord compression and CTG
With supine breech birth, once the shoulders are born, you have to hurry deliver the baby because the weight of the baby is compressing the cord. But with upright births, the baby doesn’t compress its cord—it decompresses its cord! When woman is upright, the only time you have a pathological CTG is with true pathology.

Posterior presentations
A posterior baby during a vaginal breech birth would be considered pathological and in need of assistance. When the woman is on her back, you have to turn the baby 180 degrees with your hands On hands & knees, the situation might resolve itself spontaneously. (He showed us a film clip of this happening.)

Normal vs. pathological
Frank reiterated that vaginal breech is normal. If you don’t need any intervention, it’s normal. If you need an intervention, it’s pathology. More than 90% of all breech deliveries are normal and spontaneous if the baby is normal sized, frank breech, and anterior. Normal sized = not too small. Big babies are not a concern. Putting a woman on her back even in cephalic births is pathology because it requires an intervention (releasing the shoulders once the head is born).

“Never pull, only push the baby.”

Pathological situations in breech births:
1. Weak contractions during pushing.
2. Dorsal posterior (if they don’t turn themselves in labor).
3. Footling presentation. When the woman is on her back, you often see pathological CTGs during the birth. In the upright position, you sit, watch, and encourage the mother to push during contractions, not in between. If you want to check CTGs, do it directly on the baby’s chest, not on the mother’s belly!!!

Women in his unit are not required to have epidurals; it depends solely on the mother’s wishes. 2/3 have them and 1/3 don’t. He noted that women need activity in labor, so a walking epidural is a must. If your unit can’t do true walking epidurals, he advises against them.

Rixa's note: We saw several films of women on his unit with walking epidurals. The women seemed to have a full range of movement and were able to squat, stand, and walk on their own.

Q&A session

Q: Midwifery students in the Netherlands are taught breech as an emergency skill, since they have to refer known breeches to their OB colleagues. So the midwives only have training in breech on the back with Lovset & Bracht maneuvers and an episiotomy. I'm trying to convince my midwifery colleagues to teach breech on all fours. But they say because it’s an urgent situation and they are not experienced, we should not teach them that. What is your opinion on that? What should we teach midwives who might not do a lot of breech births?
A: How many vaginal breech births do you need to attend until you’re experienced? We are living in another age with the availability of video clips. You can see thousands of breech births by watching video clips again and again. In the first 200 or so vaginal breech births I attended, I had high levels of adrenaline. Now I can just sit back and watch, relaxed. I often don't remember my first-hand breech experiences because I am so in-the-moment. Video clips, on the other hand, can give us experience. Ask women to allow you to film their births. Since I started, I have always said that the video belongs to the woman and she may share if she wishes to give her permission. You get really experienced by watching vaginal breech birth on videos. I encourage you to use the techniques of the 21st century, not of the 19th century. Use videos again and again. Pause it. Examine it closely. Then you can attend ten or so births in a unit and I would consider you ready to go.

Q: What is your opinion about speed of delivery of the head in an upright position?
A: If the baby is fine, you can wait. If there’s a pathological situation (prolonged 2nd stage, etc), you can help the head by doing a shoulder press. But if it’s normal, you just wait.

Q: What about quick decompression of the head?
A: No relation to any pathology. Not a complication. Just let the head come out, slow or fast.

Q: In a midwifery school, you still too often learn with women on their backs. We need to be very conscious of our history and of how paternalistic our system has been towards women. We must remember to see childbirth from a human perspective. As professionals, we shouldn’t focus on taking over and controlling the woman. It’s crazy how we as providers start turning the world around. We need to support women in choosing the position they want to be in.
A: We have to be the expert to recognize immediately when there is any pathology. We don’t have to influence the normalcy. We have to realize how can we detect pathology as early as possible and which intervention would be the best to correct it. If we realize that we don’t have to view breech in general as a pathology, then we are ready to really discover what is pathology and what is not in a vaginal breech birth. The Hannah trial was just comparing two pathological situations.

Q: How many patients are you hoping for in your own trial?
A: I'm not looking to detect mortality rates, but to compare the necessity of maneuvers. The Frankfurt data has been submitted for publication. In it, we found a significant reduction in maneuvers using hands & knees vs on-the-back positions. Interventions lead to more complications. So if you have fewer interventions, you have fewer complications. Our study had about 350 in both groups. I'd like to conduct an international multi-center study comparing the same things.

Q: You said something about a "normal sized baby" meaning a baby that is not too small. What is not too small?
A: A baby that is big doesn’t result in higher complications for the baby (such as low Apgars, NICU, etc). But unplanned in-labor cesareans (also called secondary cesareans) are higher with big babies. In my data, the bigger the baby or the smaller the pelvis, the higher the cesarean rate is at the end. But bigger babies aren’t related to higher neonatal mortality. On the other hand, smaller babies are related to higher complication rates, so they can be an indication for CS. My cutoff is somewhere around 2,000 - 2,500 grams. It’s a tricky number to pin down exactly.

Sources cited:

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First Amsterdam Breech Conference: Welcome Speeches

I just returned from the First Amsterdam Breech Conference, a 2-day conference presenting evidence, theory, and hands-on training for vaginal breech birth. I will be posting summaries of each presentation. I did my best to accurately summarize each speaker, but if I missed something important or misrepresented, please contact me or leave a comment, and I will gladly revise!

Day 1 began with welcome speeches by the conference's organizers: Fedde Scheele, Ruth Evers, and Joris van der Post. The conference was attended by 230 people from 11 countries, of which 91.3% were women and 8% with English as their native language. From a show of hands, roughly half of the attendees were physicians or medical students and the other half midwives, with a scattering of doulas and academics. You can find conference updates via Twitter at #teachthebreech

Dr. Post is a professor at one of the two teaching hospitals in Amsterdam. He noted that today, the big question is how to avoid a cesarean when you have a breech baby. He gave three short pieces of advice to practitioners:

1. Clearly know your definitions and terms when counseling clients
2. Your training and skills must be in order
3. Know all the possibilities that can happen with breech, both complications and variations of normal

After reviewing the drastic changes in cesarean rates after the Hannah Term Breech Trial (TBT), he noted that the conference will strive to answer this question: how should we counsel women with breech babies, and what is the evidence?

Next was Dr. Scheele. He noted that how we look at the data is of enormous importance. He has learned from both midwives and their patients that breech is not only about safety figures—this was difficult and strange, to learn this at first, as he was trained in a safety mindset. For midwives, it’s about safety AND about the experience of birth for the woman. With his doctor’s mind, it was difficult to give that idea a place. While a cesarean section might seem like the optimal experience of safety, it’s not the optimal way of birth for many women.

Finally, Ruth Evers spoke. She worked as a midwife for several years and now is a trainer/coach at Talmor. She joked that in this conference, the chance of being male was twice as high as the chance of having a breech presentation! She showed a brief clip from the documentary A Breech In the System and introduced a series of filmed interviews with Dutch women—all mothers of breech babies—they would be presenting throughout the conference.
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