Tuesday, August 27, 2019

To remember the Louwen maneuver (shoulder grip rotation)...just follow the rainbow!

If you attend upright breech births, you may have used the Louwen maneuver (shoulder grip rotation). It can be tricky to remember which way to rotate first and how far around. So I came up with this illustration.

Remember: the baby follows the rainbow across the sacrum, then comes back to mama

(It's the same process in mirror image for a LST breech)

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Tuesday, August 13, 2019

Manhattan Breech Workshop

After months of waiting (and a last-minute venue change), we are thrilled to announce the Manhattan Breech Workshop! It takes place at NY Open Center (near the Empire State Building) on Oct 26-27. To register: bit.ly/manhattanbreech

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Wednesday, August 07, 2019

RCOG and SOGC estimates of term breech mortality

With the recent release of the 2019 SOCG breech guidelines, I created this updated graphic. It illustrates the likelihood of perinatal/neonatal mortality after vaginal breech versus planned cesarean section.
Using the RCOG's numbers, the *additional* risk of a vaginal breech birth, compared to a vaginal head-down birth, is 1/1000.

Here's another way of looking at it:
Baseline risk of mortality after pCS @ 39 weeks: 1/2000
Additional risk from last weeks of pregnancy & labor: 1/2000
Additional risk of a vaginal breech birth: 1/1000
Ps, if you liked this post, would you please consider donating to Reteach Breech? Thanks to a matching grant, all donations will be doubled AND all perks are half-price! Donations are tax-deductible in the US.

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Sunday, August 04, 2019

Support Reteach Breech and double your donations & perks!

Exciting news--thanks to a generous matching grant, all donations to the Reteach Breech campaign will be matched AND all perks will be doubled.

For example, if you donate $25, you'll get access to the breech workshop videos (normally $50) AND your donation will be doubled to $50!

Other amazing perks you can get...

  • T-shirt for $30 (normally $60)
  • Onesie for $38 (normally $75)
  • Athletic t-shirt or flowy tank top for $50 (normally $100)
  • Linocut for $50 (normally $100)
  • Klean Kanteen insulated thermos for $75 (normally $150)
  • Maternity t-shirt + baby onesie for $100 (normally $200)
  • ALL THE THINGS for $200 (normally $400)

Donations will be doubled and perks will be half-price, up to $5,000 or until the end of the fundraiser, whichever comes first.

Donate today before this amazing offer runs out!

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Wednesday, July 31, 2019

Prince Edward Island Breech Workshop

Register now for the Prince Edward Island Breech Workshop Sep 28-29. This is the only Canadian workshop offered in 2019. To register: bit.ly/peibreech

Thanks to a generous donation from the Coalition for Breech Birth, we are offering two scholarships to the workshop for Canadian providers: one for a physician/resident/medical student and one for a midwife/midwifery student. Any Canadian provider may apply; preference given to providers serving the Maritime provinces & Newfoundland.

To apply: Send an application letter to breechworkshop@gmail.com. Please state your province, qualifications, and how you plan to use the knowledge gained in the workshop in your community.

Deadline: August 14

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Monday, July 29, 2019

Prince Edward Island Breech Workshop Scholarships

The Coalition for Breech Birth has generously donated funds to sponsor 2 scholarships to the Prince Edward Island Breech Workshop! Any Canadian provider may apply; preference given to providers in the Maritimes & Newfoundland.

1 scholarship is for physicians/residents/medical students
1 scholarship is for midwives/midwifery students

To apply: Send an application letter to breechworkshop@gmail.com. Please state your province, qualifications, and how you plan to use the knowledge gained in the workshop in your community.

Deadline: August 14

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Monday, July 15, 2019

Please donate to "Reteach Breech"

My years of breech research and advocacy have finally come to fruition! Please donate generously to Breech Without Borders' fundraising campaign so we can reteach breech. We are raising funds to purchase two obstetrical simulators for our breech training workshops.

If you have ever benefited from reading my blog, following my children's births, watching my educational breech videos, or sharing my breech infographics, please donate today.

If you care about women's autonomy in childbirth, please donate.

If you care about reducing the cesarean rate, please donate.

And of course, please share widely!

I want to create a world where every provider has vaginal breech skills and where every woman can choose how her breech baby is born.

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Sunday, July 14, 2019

Madison Breech Conference: Envisioning Autonomy, Biodiversity, and Sustainability

Save the date for the Madison Breech Conference on Nov 9-10! The conference focuses on 3 main themes: autonomy, biodiversity, and sustainability in breech birth.

We'll be discussing barriers to providing breech birth, as well as solutions for providers and administrators. We'll be listening to providers share their struggles and triumphs in supporting breech birth in their various settings: from rural to urban, from family medicine to midwifery to maternal fetal medicine, from supportive hospitals to hostile hospitals. We'll learn about breech birth from a human rights attorney and from a journalist who writes about women's experiences of pregnancy and birth. And of course we'll be teaching breech birth, with hands-on simulation training and an emphasis on physiological breech birth.

This is a conference you don't want to miss! Stay tuned for updates.

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Friday, July 05, 2019

Auckland, NZ Breech Workshop

Breech Without Borders is bringing four breech workshops to New Zealand in November and December. The first takes place in Auckland on Nov 25-26. It will be held at the Kawai Purapura Retreat Centre, just north of Auckland.

Click here to register.

The workshop costs $450 NZD ($350 for students) and includes 15 hours of instruction and hands-on practice. We have applied for continuing education credits through the Midwifery Council.

For more information about the workshops and instructors, please visit www.breechworkshop.com.

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Monday, June 10, 2019

Western Pennsylvania Breech Workshop

Breech Without Borders is offering a breech workshop in western PA on Sep 21-22. The workshop is ideal for birth attendants in W/central PA, E/central Ohio, western New York, northern West Virginia, and western Maryland.

The workshop includes 15 hours of instruction and hands-on training. To register: https://breechwithoutborders.ticketspice.com/western-pa-breech-workshop

Optional NRP certification on Sep 20.

For more information about the workshop: www.breechworkshop.com

Breech photo credit: Karyn Loftessness Photography
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Sunday, June 09, 2019

Detroit Breech Workshop

Breech Without Borders is offering a breech workshop in Detroit on Nov 2-3. The workshop includes 15 hours of instruction and hands-on training. To register: https://breechwithoutborders.ticketspice.com/detroit-breech-workshop

For more information about the workshop: www.breechworkshop.com

Breech photo credit: Karyn Loftessness Photography
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Saturday, June 08, 2019

Central Indiana Breech Workshop

If you live in Indiana, western Ohio, eastern Illinois, or northern Kentucky, please consider attending the Central Indiana Breech Workshop! It is located in the Indianapolis metro area and offers 15 hours of instruction and hands-on training.

To register: https://breechwithoutborders.ticketspice.com/indiana-breech-workshop

For more information about the workshop: www.breechworkshop.com

Breech photo credit: Karyn Loftesness Photography
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Friday, June 07, 2019

Dallas Breech Workshop

Come to the Dallas Breech Workshop on Oct 9-10 at the Addison Conference Centre. We are approaching our registration cap, so act quickly to reserve your spot. To register: https://breechwithoutborders.ticketspice.com/dallas-breech-workshop

To learn more about the workshop: www.breechworkshop.com

Breech photo credit: Karyn Loftesness Photography
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Wednesday, June 05, 2019

Memphis Breech Workshop

Registration is now open for the Memphis Breech Workshop on Oct 4-5. Take advantage of early bird prices through June 30. Registration includes lunch and snacks both days.

To register: bit.ly/memphisbreech

Accommodations are available at the Mayberry Hill Homestead ($50/night per bed). Please contact LyndaHoskins@bellsouth.net to reserve.

Breech photo credit: Karyn Loftesness Photography
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Monday, June 03, 2019

Prince Edward Island breech workshop

Are you a birth worker in PEI, New Brunswick, or Nova Scotia? Come to the PEI Breech Workshop on Sep 28-29. Registration is now open.

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Sunday, June 02, 2019

Dover Breech Workshop

Breech Without Borders is bringing several workshops to North America and New Zealand in 2019! Our first workshop takes place in Dover, NH on August 17-18.

Ideal for midwives, physicians, and other birth workers in New England and southern Ontario.

This 2-day workshop provides 15 CEU contact hours (MEAC & ACNM). You'll receive both theoretical instruction and hands-on training with obstetrical mannequins. Space is limited and early bird pricing ends June 30. Wentworth-Douglass employees receive a 25% discount. 

To register: bit.ly/doverbreech

To learn more about the workshops, please visit www.breechworkshop.com.

Breech photo credit: Karyn Loftesness Photography
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Saturday, March 23, 2019

Breech love

Let's send some unconditional love to all those little breechlings with stressed mamas who have few or no options for a vaginal birth.

Let's demand that every hospital offering maternity care also offer 24/7 access to vaginal breech birth...because a mandatory cesarean violates basic human rights, legal rulings that uphold the right to refuse surgery, and medical ethics.

Let's teach midwives and physicians, in or out of hospital, how to do a vaginal breech. Standing or sitting. Kneeling or supine. Water or land.

(Linocut made by me...breech is always on my mind)

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Friday, January 04, 2019

Is examining home breech outcomes problematic? A response to Hilda Bastian

After the publication of my article Breech birth at home, co-authored with Dr. Stuart Fischbein, we were invited to write a guest blog for Biomed Central. We wanted our paper to start a conversation about breech birth generally, and breech birth at home specifically. With access to vaginal breech birth in hospital settings nearly nonexistent in the United States, women who want to avoid a cesarean section often have no choice but a home breech birth. Some of these would choose a home birth even if a hospital option existed, while others would prefer a supportive hospital setting.

A few days ago, several people alerted me to a blog post objecting to the publication of our article. Written by Hilda Bastian, the post was titled The Dangerous Allure of Breech Birth at Home – and a Problematic New Paper.

If I had the chance to sit down and have lunch with Hilda, here are some thoughts I would share.

First, I am grateful that she took the time to write up her responses and to be so thorough with her bibliography. I am an academic, and I love long lists of references! She included several that I hadn’t looked at yet since they did not come up in my literature searches (“breech” and “pelvic presentation” were my primary keywords). I will add them to the lecture on home breech outcomes that I give at my breech workshops. A sincere thank-you for that. (To date, my current lecture references Mehl-Madrona 1997, Bastian 1998, Johnson 2005, Deline 2012, Cheyney 2014, Cox 2015, Fischbein 2015, Bovbjerg 2017, Gr√ľnebaum 2017, and Fischbein & Freeze 2018).

A slide from one of my breech workshop lectures.
Hilda critiqued us for only including 4 studies about home breech outcomes in our introduction. This was in part a deliberate decision as we had already far exceeded the normal number of references for a research article (many journals limit the number of references to 25-30). We chose to include those 4 studies as they had the largest datasets of home breech births.

When I give my lecture on home breech outcomes, I usually start it by saying, “If you are a home birth provider, this is going to make you very uncomfortable. The numbers do not look good.”

I am surprised by Hilda’s certainty that the question of breech birth at home has been answered for good. I don’t disagree that the existing literature shows poorer outcomes for home breech birth. But—and this is very important—we also found that these studies lacked information about nearly every aspect of a planned vaginal breech birth: training and experience levels of the birth attendants, selection criteria, labor management, maternal motivations for choosing a breech at home, or local hospital options for a breech presentation. None of these factors were measured or studied.

In other words, all we have are raw numbers: X number of breech babies had poor outcomes. We don’t know what caused those higher levels of bad outcomes. With the existing research, we could only speculate: Was it lack of adequate experience with some of the attendants? Lack of ultrasound to confirm head flexion? A mother insisting on having her baby at home and the midwife agreeing to honor her autonomy despite less-than-optimal circumstances? Undiagnosed fetal anomalies? Problems with hospital transports?

Our study is significant because it was the first to begin answering these questions. We know the provider’s skill level, selection criteria, and labor protocols. We know what equipment was present at the birth and the training of the entire birth team. We know why women chose home birth and what the local hospital options were (very few, if any, which led women to seek Dr. Fischbein’s services).

Yes, there were some poor outcomes, and we gave information about the circumstances and sequelae surrounding each one. Although we didn’t have complete medical records for some of the hospital transfers, the parents personally transmitted information about their hospital stays to Dr. Fischbein. We reported all adverse outcomes whether in hospital or at home. (The author suggests we might have left some unreported.)

There was one brachial plexus injury (ongoing at 6 months of age) that occurred at home after a terminal bradycardia and subsequent maneuver to help the baby be born quickly. The other 4 adverse outcomes all occurred after the women had transported to a hospital in stable condition due to stalled labor. 3 of the 4 were neonatal morbidities; they occurred with a receiving physician who offered augmentation and vaginal delivery with forceps and vacuum extraction if needed. One neonatal death occurred when a woman was admitted for a cesarean due to stalled labor, and the surgery was inexplicably delayed for more than 2 hours.

From an intention-to-treat paradigm, all of these poor outcomes would be attributed to home birth as that was the original intent at the beginning of labor. However, Dr. Fischbein and I believe that the circumstances that led to poor outcomes in the hospital transports were not primarily related to the planned location of birth.

I participated in the first two Home Birth Consensus Summits in 2011 and 2013. One area of consensus was that hospital transports need to be seamless. When women fall through the cracks, they and their babies suffer the consequences (as we can see with the one neonatal demise). The solution isn’t to outlaw homebirth, but rather to work on better collaboration and communication so women can move from home to hospital with loving support, professionalism, and respect from both the transporting and receiving care teams. Please refer to the summit's Best Practice Guidelines.

I don’t expect everyone to support home birth with a breech presentation. However, I want to keep dialogue open. I worry that the author’s rhetorical techniques stir controversy rather than engage productively in making birth better for women with breech babies. For example, the author used click-bait titles (“the dangerous allure of breech birth at home”), chose emotionally-charged language (“dangerous and misleading,” “go off the rails,.” midwives who are filled with “hubris” and involved in the “heady stuff of euphoric legend-making”), and misrepresented my qualifications (she says I am a “doula and midwife’s assistant” and neglects to add that I have a PhD). To give Hilda credit, I don't think this last omission was intentional.

I’d like to step away from the fiery rhetorical flourishes and instead talk about the reality of what’s happening on the ground. Right now. With women in California or Oklahoma or Connecticut who are 39 or 40 weeks pregnant and have just discovered their babies are breech and have no options but cesarean at any hospital, anywhere.

To quote from the musical Hamilton, we have "three fundamental truths at the exact same time”:
  1. Hospitals in the USA continue to refuse to offer vaginal breech birth. Some even ban it despite having providers willing to attend vaginal breech births.
  2. Women continue to find a mandatory cesarean unacceptable.
  3. Breech is happening at home.
We can stay in the stratosphere of rhetoric and idealism, bemoaning the dangers of home breech birth. But I prefer to stay firmly rooted on the ground. It’s pointless to argue that home breech birth shouldn’t happen when there are no other alternatives offered. And none foreseeable in the near or distant future, either. ACOG certainly hasn’t done more than give watered-down lip service to vaginal breech birth. Even the SOGC’s vigorous support of vaginal breech training and re-education has done little to move the needle in Canada.

So that leaves us with this reality: breech is happening at home. How safe is breech birth at home, and can it be made safer? Our study only begins to answer those questions. The solution isn’t to stop asking the questions altogether because ACOG considers breech at home an “absolute contraindication.” (If we took ACOG at their every word, we wouldn’t be having any home births at all!) Instead, we need to keep seeking out more information. We need larger datasets of planned home breech birth with skilled attendants.

I am thrilled to announce that I will be working on one such dataset in the near future: over 550 vaginal breech births with a single home birth midwife. I know of another team currently doing data entry with another midwife’s breech outcomes (again, with numbers in the several hundreds). Between these two datasets, we might have 1,000+ home breech births to analyze. This far exceeds any of the largest datasets on home breech we have so far. Grunebaum’s birth certificate data (2017) included 553 breeches. Johnson (2005) had 80. MANAStats 2.0 and 4.0 combined had 539 breeches (Bovbjerg 2017). And unlike these other studies, we can account for numerous variables.

More importantly, I am on the ground actively training providers—midwives or doctors, home or hospital, anyone is welcome!—in vaginal breech birth. Under the umbrella of my nonprofit Breech Without Borders, I provide a full day of academic lectures on term breech outcomes (both home & hospital), maneuvers, normal & abnormal mechanisms, and nomenclature systems. An experienced physician or midwife colleague then provides another full day’s worth of instruction and hands-on training. I am optimistic that, with good training, we can make vaginal breech birth safer and more satisfying in any setting. I am disappointed that, to date, midwives have outnumbered physicians, residents, and medical students more than 50:1 in our workshops (and not for lack of invitations on our part!).

No matter if you vehemently disagree with breech birth at home, wouldn’t a policy of harm reduction (providing as much training & education to the people who are actually attending breech births) be better than simply stating it shouldn’t happen or, even worse, attempting to outlaw it (which will lead to some women choosing unassisted birth rather than being forced into a mandatory cesarean)?

I’ve gone on long enough. Dr. Fischbein and I both feel that our paper and our blog post speak for themselves. Take a minute to read them, and then come back and share your thoughts.

And more importantly, get out into your community and start demanding that your local hospitals offer vaginal breech births! Breech Without Borders will bring a vaginal breech workshop to any community that wants it.

Dr. Rixa Freeze, PhD
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