Ken Johnsson & Betty-Anne Daviss: The Frankfurt Study

First Amsterdam Breech Conference, Day 2

Ken Johnson & Betty-Anne Daviss

Rethinking the Physiology of Breech Birth: 

A Cohort Study in Frankfurt, Germany, 2004-2011

Betty-Anne Daviss opened the session by remarking that this study has been a long time coming; she’s been working on it since 2008. It is a collaboration between Frankfurt and Ottawa involving Frank Louwen, Anke Reitter, herself, and her epidemiologist husband Ken Johnson.

from Spinning Babies

When Betty-Anne and Ken spoke in July 2016, the manuscript had not yet been published. It is now available (without cost) in the International Journal of Gynecology & Obstetrics: Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. If you scroll down to "Supporting Information," you will find additional tables and a video showing a hands and knees breech birth at the Frankfurt clinic.

B-AD: Research over the last several decades has focused largely on comparison between vaginal birth and elective cesarean section (ECS), and almost no focus on how to improve vaginal breech birth (VBB). She finds that sad. Most of the large registry studies (such as the ones done in the Netherlands, Canada, or the U.S.) appear to have a higher neonatal mortality and/or morbidity with VBB than with ECS. But the registry studies do not capture the details that the cohort studies do.

There are other problems. In Canada, when Lyons et al published their registry study, the conclusions read that the neonatal mortality and morbidity rates were higher with vaginal breech birth. What the abstract did not make clear was that because the outcome measure was reported as a composite variable. Although the two outcomes were reported together as "higher," it was only the morbidity, not the mortality, that was higher. In fact, when she and Ken went to the actual table, the neonatal mortality (NNM) was clearly reported as "0" and the morbidity was, no doubt, not long-term (as in the Term Breech Trial). But if you only look at the abstract and can't wade through the real meaning of the study, you get terribly fearful of vaginal breech birth. And that fear is difficult to undo.

Betty-Anne suggested that we look at cohort studies done in units, like in France, Belgium, Dublin, Newcastle, Norway, and Frankfurt. In all of these places--with skilled attendants, good screening, and protocols--almost invariably the difference in NNM is very negligible.

Today she and Ken are presenting what it looks like to compare two kinds of vaginal birth. It wasn’t an intention-to-treat study; rather, it compares what actually happened. For more understanding of concerns about relying only on RCTs such as the Term Breech Trial and the history of some of the breech research, refer to Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions.

KJ: (Next, Ken presented some information on the premature breeches, which they excluded from the study, but were interesting nevertheless.)

The Frankfurt study included 750 term breeches. 42% were scheduled cesareans; half of those cesareans were by the mother’s choice. The Frankfurt cohort had a high number of primips. Most of the vaginal breech births ended with the mothers upright. They also looked just at the last 2.5 years at the clinic, since they were almost exclusively doing upright births at that point. With mothers exclusively upright, they saw slightly higher success rates.

B-AD: This is an observational cohort study, not a randomized controlled trial. We are looking at what is, not at what’s planned. That is, the cohort study describes what has happened at each birth in the natural process of a particular delivery unit, without instigating or removing parameters, as with the randomized controlled trial. Observational data in a unit can thus be very useful and has some merit of itself that can be more useful than randomization.

But it does raise the question: how do people decide what position they end up in? We explain that in the study.

KJ: Having a woman upright resulted in fewer maneuvers. Forceps and episiotomies were never needed in any of the vaginal breech births.

B-AD: We didn’t collect information about fundal pressure in the database, which is actually used frequently, so that would be useful to do in the future.

KJ: Upright maternal positioning resulted in fewer neonatal injuries and a shorter 2nd stage of labor. How do they define 2nd stage in Germany? It starts at full dilation--not at the onset of spontaneous maternal pushing--so it includes a latent stage. This explains some of the longer 2nd stages recorded in the Frankfurt study.

The Frankfurt study used the definitions of fetal and neonatal mortality & morbidity in the PREMODA study. This allows us to compare the Frankfurt data to the PREMODA study and to the TBT (upon which PREMODA was based).

B-AD: This database is incredibly useful. We need to have more of these databases to amplify this area of knowledge. Observational data in cohort studies is really valuable to individual hospitals so they know what is going on and to compare notes with other units. Collect your data in your unit!

(I had to leave right as they started the Q&A)

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

First Amsterdam Breech Conference, Day 2

Andrew Bisits

Establishing a training course in breech vaginal birth in Australia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

~~~~~

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

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

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

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

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Anke Reitter: New Insights from Pelvimetric MRI Studies and Maneuvers for Upright Breech Birth

First Amsterdam Breech Conference, Day 2

Anke Reitter

New Insights from Pelvimetric MRI Studies

Dr. Anke Reitter is a Fetal Maternal Medicine Specialist at Krankenhaus Sachsenhausen, Frankfurt. She specializes in breech, multiple pregnancies, high-risk pregnancies, ultrasound--and is also an IBCLC!

Anke began with an analogy: if you are in love with a soccer team, you follow them enthusiastically. It’s the same with being a breech activist. Her study will seek to put the data into practice and look at the mechanisms and physiology of breech birth.

She began by addressing the data on term breeches from the university hospital where she had worked with Dr. Frank Louwen. (See the recent publication Does breech delivery in an upright position improve outcomes and avoid cesareans? IJOG 2016; manuscript accepted.) Women came from all over Germany to this clinic to have their breech babies. Now she’s in a new clinic, building up a breech service in a hospital that didn’t previously offer vaginal breech. She noted that most women coming to Frank’s unit for breech births were primips (about 70%).

Anke noted that the RCOG's 2006 guidelines suggested lithotomy position for breech, but the new April 2016 guidelines now endorse all-fours (currently in process, to be released soon). This gives us a safety backup by having this information in the RCOG guidelines. We can change things. The new guidelines also have a summary for safe breech births.

Pelvimetry & Primip Breech

Anke next presented her unit’s safeguards and selection criteria, in particular the role of pelvimetry for primips. She feels that doing MRIs for primips gives them an extra safety cushion. The PREMODA study also recommended “normal pelvimetry.” She referenced a study by Van Loon et al (RCT of MRI pelvimetry in breech presentation at term, Lancet Dec 1997). One group’s MRI data were shown to the physicians, and the other group’s data were hidden. Many factors were the same, but the emergency cesarean rate was lower in the group where physicians knew the pelvimetry data.

Anke wants to compare the Frankfurt MRI data to the Van Loon data—does anyone know how to do this? In the Van Loon study, all women were allowed to labor, whereas her unit excluded some women due to their pelvimetry results.

Anke presented preliminary results from another study she's authoring on primips* with breech presentations. They measured the obstetric conjugates of this group of 371 women. They excluded women with an obstetric conjugate of less than 12 cms (19%). Of the remaining primips who planned a vaginal birth, over 53% had successful vaginal breech births. Annke noted that if you use pelvimetry, you have to accept that you’ll deny some women a chance at a VBB who might have been able to do it successfully. I don't have any more information on this study, except that the manuscript has been submitted.

(*If I understood Anke correctly, this means functional primips, i.e., no previous vaginal births. This could include women with previous cesarean sections).

MRI study on maternal position & pelvic diameters

Next, Anke presented results from her MRI study Does pregnancy and/or shifting positions create more room in a woman's pelvis? (J Ob Gyn, Jun 17 2014). The study examined how pregnancy or changing positions changed the pelvic dimensions. They scanned 50 pregnant women and 50 non-pregnant women (mostly midwives from their unit). Each woman was scanned in both a “modified squat" and in a dorsal spine position.

Anke's research team measured the pelvic inlet, the midpelvis, and pelvic outlet (a total of 6 measurements). The results were really exciting: modified squatting makes the pelvic inlet slightly smaller, while the midpelvis and outlet are larger. As midwife Anne Frye says, when the baby isn’t engaged yet, don’t get the woman squatting. Anke commented, "You midwives already knew that, but as a doctor I didn’t know that!"

The same thing happened in the non-pregnant group, and all of the results were statistically significant. Anke was surprised because she’d thought that the obstetric conjugate would widen with a squat, but it narrowed while the other measurements opened.

She also looked at the transverse diameter using several different measurements and noticed striking results: Big changes are happening in the transverse diameters, even more than in the first 6 sets of measurements. They observed the same results in the pregnant and non-pregnant groups. They were very surprised and very happy to see that.

Anke concluded that this MRI study doesn’t mean you have to scan every woman, but it helps explain the advantage of upright positions for both cephalic and breech babies.

Giving credit where it's due, Anke noted that upright birth positions have been used for a long time, especially with midwives.

Anke also mentioned Andrew Bisits’ work in Australia. He recently published his data in Lessons to be learnt in managing the breech presentation at term: an 11-year single-centre retrospective study (AustNZJ Obstet Gynaecol 54.4 Aug 2014.) Although most of the breech births occurred in an upright position on the BirthRite birth stool, his article only spent one sentence describing the mothers' positions. His unit's vaginal breech delivery rate was 58%.

How do we put all this into practice? 

Anke noted that we have (re)discovered new maneuvers for freeing nuchal arms and assisting the delivery of the head. With upright breech, we need fewer maneuvers compared to supine breech births (see Louwen et al 2016).

As a side note, Anke highly recommended the MODEL-med obstetric mannequin for simulation training (pictured below). Andrew Bisits has been helping the company improve the doll so the arms articulate correctly.

Know the signs of normal & abnormal with the all-fours position 
Normal: the baby's trunk faces forward
Abnormal: the baby's trunk faces sideways

Signs of normal & abnormal rotation with a supine breech:

Anke discussed this 1958 Australian textbook illustration: with a nuchal arm, the body is usually not in a front-facing position—it’s usually transverse. So the arm is drawn correctly, but not the body.

In this 1986 German textbook, she found a good illustration and instructions with the drawings done correctly. You'll see that the body of the baby remains transverse rather than A/P. This illustration shows the proper direction of rotation to try first (the baby's arm points the way).

Direct maneuvers for hands-and-knees:
1. Recognize sign of dystocia (trunk not rotated to the front)
2. To free a nuchal arm: Louwen Maneuver. Rotate 180, then 90 the other direction. Baby's hand points the way for the first rotation. Baby should end facing the mother's anus.
3. To flex the head, do one of the following:

1. Shoulder press or "Frank's nudge": press on the baby's shoulders backwards towards the mother's pubic bone (not downward). Rixa's note: I have seen two variations of the shoulder press, a.k.a. "Frank's nudge," demonstrated at this conference. Anke Reitter prefers holding the baby by its shoulders, the thumb in front and the fingers wrapped around the back of the shoulders. Others place 2 fingers (index & middle) on each shoulder and press backwards gently.

2. Subclavicularly Activated Flexion and Emergence (SAFE): Gently press the sub-clavicular space to elicit a flexion response in the baby. Gail Tully discussed this in depth in her presentation on Day 1.

Indirect maneuvers for hands-and-knees:
1. Gluteal lift: Lifting up the mother's gluteal muscles helps release some soft tissue. This is usually used to assist the birth of the head.
2. Forward lift: Firmly push the mom forward; this pushes her pelvis forward and helps the baby’s head release.

Anke concluded by summarizing the key elements of a vaginal breech service:

~~~~~

Q: In Holland we don’t use pelvimetry. Do you let a multip with a small obstetric conjugate still plan a vaginal breech birth?

A: We do MRI scans on women with no proven pelvis. (I.e., that woman wouldn’t have had an MRI at her clinic since she had a "proven pelvis.")

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Leonie van Rheenen: Free choice in birth position, change of practice…An obstetrician's point of view

First Amsterdam Breech Conference, Day 2

Leonie van Rheenen

Free choice in birth position, change of practice…

An obstetrician's point of view

One of the "mothers" of the Amsterdam Breech Conference, Leonie van Rheenen is an OB/GYN and is used to working in close collaboration with midwives. The session's announcer noted that for the first time in his life, he's seeing midwives and physicians working and learning together in close cooperation--thanks to this conference. 

Leonie convinced her physician group to shift from supine to all-fours positions in just 6 months. For change management, that’s spectacular--and all due to Leonie's leadership. Leonie and others wanted to learn more, so they initiated this breech conference.

Leonie opened her presentation by saying that her dream has come true: it’s happening and we’re all coming together at this conference. She's already thinking about the next breech conference—possible topics include the 1st stage of labor, monitoring, dilation, trapped heads, and more!

Leonie's presentation was about how an obstetrician came to learn about, accept, and start attending upright breech births. So how did it all begin? Leonie came to work at OLVG. She began as a young OB/GYN, having attended just 7 vaginal breech births during her residency (plus some breech twins and preemies). This hospital had a tradition of breech births and she needed to be able to do them on her own. It gave her some doubts.

They collected numbers on their breech patients. Women have a 60-80% chance of a successful vaginal breech in her hospital. However, most women choose a planned cesarean. Are these numbers (on average, 41 attempted and 28 successful vaginal breech births per year) enough to keep up physicians' experience? She doesn't know.

Leonie needed a mentor to help her with vaginal breech birth. She saw that people were posting clips and videos online and on social media. She saw breech births on all-fours and at home, and it was really new to her. She found out about a course in Sheffield to learn breech skills.

Leonie told a story about being on call when a primip came in labor with a breech baby. At this point she had read about upright breech births and watched YouTube videos, but had never seen one in person. All was going well with a relaxed atmosphere. The mother was standing next to the bed, moving and wiggling her pelvis. She became fully dilated and started pushing. Somewhere during the labor, Leonie asked the mom to go on the bed, and the mom said she didn’t want to. So there Leonie was with this excellent birth, everything going well. The midwife asked Leonie if she was going to ask the woman to lie down on the bed again.

She thought about it. She went through several stages as she considered whether she was okay with attending a breech birth on all fours--something she had never done before:

1. No, never, it's impossible!
2. I don’t see any advantages. Why is it better?
3. How can I learn? How can I get enough experience?
4. What if…

She started to think, There isn’t really evidence for being on your back; it’s more tradition than anything else. But how am I ever going to learn to do breeches on all fours? And on top of that, she was thinking, How can I tell this mom that I’ve never done it before and only have seen it on YouTube?!

She came up with a solution: she placed the mom upright between the stirrups so the mom could stand up and lean over. If Leonie needed to, she could sit her back down. The mom birthed the baby perfectly. She saw the baby do the tummy tuck and, thanks to YouTube videos, she knew the baby wasn’t gasping or in any danger.

Afterward outside the birth room, the birth team gave each other a big High-Five!

Her experience from attending upright breech births:

• Don’t focus on all fours, and don’t start that position too early (especially for primips). Find out what’s best for the woman at that moment.
• Try to find the easiest way and change labor positions.
• Keep the same rules as in lithotomy.
• Train your team. The first time they might be a bit disoriented, but if they’re well trained they’re not nervous and know what to expect.
• Work on exposure/experience: by attending together, use video. Try to get permission to film and share if women are willing. If you have experience, attend with another who doesn’t have that experience. Also get residents there so they can learn.

One of the skills for breech birth is patience. For birth itself is patience!

Leonie also emphasized the importance of teamwork. In her hospital they do obstetric training every week with different teams. She suggested turning your mannequins over and training on all fours.

She showed some videos of upright breech births from her own hospital.

Leonie ended with some advice: the next time you have the opportunity to see an upright breech birth, keep these two things in mind:

• The laboring woman knows best
• You can do it! It’s not so difficult. Worst case, if you feel a bit lost, you can always turn her around and put her in stirrups if that’s how you’ve been trained. You have to start somewhere.

~~~~~

Q: I’m a midwife in the Netherlands. To gain experience with birth on all fours, are you enabling this more for women with head-down babies too at your hospital?
A: Yes, I think so we do. However, I don’t personally attend a lot of spontaneous cephalic births; once I get in there, something’s wrong. We’ve invested in wireless monitoring, which makes it much easier for women to move around. We have birthing balls and a birth pool. We have a lot of midwives working in our ward, so that helps get women out of bed. We're trying to teach our residents as well.

Q: This is not a criticism, more of a comment. We do use wireless CFM but never use a scalp clip because it hurts a baby. What is the prevalence of a Morrow reflex with the clips? My experience with breech birth is that you do pick up the fetal heart very well abdominally even on all fours. They’re a no-no in our trust.
A: I don’t think clips hurt that much. A lot of women don’t want the clip on the baby for the same reason: that it hurts. In the pushing phase, the baby is so deep in the pelvis, we lose the fetal heart rate. That’s when the team starts worrying and wants to intervene. However, if we know that all is going well with the baby, it’s easier for us to keep our hands behind our back.

Interested in Leonie's work? You can follow her on Twitter.

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Frank Louwen: Maneuvers for resolving complicated breech birth

First Amsterdam Breech Conference, Day 2

Frank Louwen

Maneuvers for resolving complicated breech birth

Dr. Frank Louwen works at University Hospital of Goethe University, Frankfurt. Other posts about Dr. Louwen include:
The re-invention of vaginal breech birth (Amsterdam 2016)
2nd International Breech Conference, Day 2 (The Germans) (Ottawa, 2009)

He just published the results of 747 singleton term breeches (433 planned vaginal, 314 planned cesarean) at his Frankfurt clinic. See Louwen, F., Daviss, B.-A., Johnson, K. C. and Reitter, A. (2016), Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. Int J Gynecol Obstet. Accepted Author Manuscript.

Knowing the movements of the baby through the pelvis is the most important thing. You compare that to what you see in the actual situation. That’s most important thing—speaking of time and maneuvers. Then you know if there is pathology or not.

How can we detect pathology early and deal with it? Breech birth is like a cephalic birth. We just have to compare what is right or wrong.

Don’t worry about explaining things to yourself. Just know what you expect, what you see, and whether or not it’s normal. With that, we are able to say if we can wait or if we need to do something.

When you first see the buttock of the baby, see where it is. Is the baby above or below the inlet? Is the hip above or below the symphysis? If it’s below the symphysis, the baby will be born very soon. If it’s above, you might have trouble and need a cesarean.

Frank doesn't recommend pushing if there is no contraction. The baby and mother need that time to rest and recover. Don’t use fundal pressure without an indication. In an upright position, the umbilical cord is decompressed and perfusion is fine.

Expect and compare. That is the most important thing.

Timing in breech birth: sometimes you have a hard job to just stand there. Complete breech is less physiological than frank breech, so sometimes they are trickier. Is the baby changing to the next position you expect? Sometimes it’s slower and you have to wait, if all is happening and the baby has good tone/color. Don’t do the Frank’s nudge before the next contraction.

In these pictures, you see the sign of dystocia: baby remaining turned to the side, rather than turned forward. If the mother is upright, the baby shows you that it has a shoulder dystocia. The baby on the left facing forward is normal. The baby on the right has a dystocia with its right arm on the symphysis. If you see that, you know the baby needs help! The child is showing you that there is that problem. If the baby turns facing you, just wait. It will happen.

Louwen’s maneuver is used to resolve this dystocia. Frank’s nudge is used later on to help flex the head if it doesn't emerge spontaneously.

Illustration from Louwen et al. 2016

The easiest maneuver for resolving dystocia is “Louwen’s maneuver:” you turn the shoulder away. To do it, you turn the baby 180° in the direction that the trapped arm is pointing, then 90° back. This gets the shoulders transverse in the inlet. We do this maneuver to turn the shoulders transverse to the inlet. That’s all. The arms might still be above the head after the maneuver, but now that the shoulders are transverse and the baby is in a much better situation. Never pull the baby out. Don’t try to get something deeper. Just move it around until shoulders are in a transverse inlet position. Then you can wait again.

Complete breeches often take longer to descend. The first leg creates a conflict in turning through the pelvis. You can use fundal pressure to see if the baby is descending into the inlet or not. But only do it when needed—you might induce the next pathology, such as a shoulder dystocia. Take the time: compare what you expect and what you really get. Always when you do an intervention, be sure you have a pathological situation first.

For Louwen’s maneuver, it’s easy to move the baby around. You don’t need too much power. Take your time. Put your fingers behind the baby’s shoulders with your thumbs on the shoulders. Don’t move the baby at the hips. You’ll be going inside the vagina—don’t hesitate but do it slowly and calmly. Don’t be afraid. You don’t need an episiotomy. Do it a full 180 degrees, not less. If you don’t finish the full rotation, it won’t work.

Detect the problem and remove the situation.

Based on the outcomes in his Frankfurt clinic, Frank strongly believes that upright breech birth “may provide a physiological advantage to perinatal outcomes compared to the dorsal position. The newly adopted position may decrease manual maneuvers required to extract the body of infants in breech position and resulting birth injuries.” 

Until now, studies have compared well-defined surgical procedures with undefined procedures in vaginal deliveries. He recommends a RCT comparing upright versus dorsal vaginal breech birth.

~~~~~

Q: You said wait for the next contraction until you do Frank’s nudge. But the head is in the pelvis and the uterus provides no pressure.
A: It’s still helpful to have the uterus contracting over the fetal head. Without a contraction, you have no push from above. The head is still inside the uterus and without a contraction you have less power.

Q: When you do Louwen’s maneuver, you do it in between contractions, not during?
A: Yes. Then once the baby is turned, you wait for the next contraction.

Q: In my experience you need a lot of power to turn the baby.
A: Yes, but it will be easier between contractions.

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Jane Evans: Mechanisms of Breech Birth

First Amsterdam Breech Conference, Day 2

Jane Evans

Mechanisms of (Upright) Breech Birth

Jane Evans is an independent midwife in the U.K. Other posts about Jane Evans include: Physiological Breech Birth and Cardinal Movements of the Breech Baby (Heads Up! Breech Conference, D.C., 2012)

This conference summary is best understood when watching Jane Evans demonstrate the cardinal movements in person. Fortunately, she gave me permission to film her at the Heads Up! Breech Conference in D.C (2012). Although you cannot see the video footage she had playing in the background, you can still follow the baby's journey as she demonstrates on a doll & pelvis.

I also recommend reading Jane's article Understanding Physiological Breech Birth (PDF) in Essentially MIDIRS Feb 2012 (pages 17-21).



Jane's goal today was to recap what to look for and and what is normal is in a breech birth, particularly when the woman is upright. She has been studying breech for over 20 years. British midwife Mary Cronk first piqued her interest in breech and set up a study day in 2003 after the TBT came out. About 30% of breeches are still undiagnosed at the start of labor, so you’ll need to know how to assist a breech birth: how not to panic, how to help if the baby needs help.

The optimal position for a baby to be in, for breech, is RSA as it drops into the pelvis. In her studies, 55% of breech babies enter RSA while 45% of the babies enter LSA. More babies that come in on the left don’t rotate. Use that observation as a little flag.

As the baby comes into the pelvis--because of the architecture of the bony pelvis, muscles, and ligaments--the baby comes in RSA, comes onto the pelvic floor, and then rotates to RSL or RST. The baby comes down in a straight line. The posterior buttock comes into contact with the mother’s sacrum, and that triggers a lateral flexion of the baby’s hips, which brings the posterior shoulder onto the back and upmost bit of the muscles in the pelvic brim.

That then triggers the baby's rotation back to RSA and continues round to direct sacrum anterior. At the top of the pelvis, that rotation brings the shoulders into line with the widest part of the pelvis. You’ll see the baby’s bum and lower part of the torso.

The body descends and the legs seem to go on forever. The baby is extending its spine. It’s very tempting to flick out the legs, but if you do that the baby won’t have to extend its pelvis so far around the mother’s symphysis pubis, which means the baby will have a harder time bringing its shoulder and head past the sacral prominence. So please don’t flick out the legs!!

As soon as you can see the baby, you won’t be able to hear the heartbeat as easily. Look at the color of the baby. Once the parts are out, look at the tone. Then look at the vitality of the cord. The knees look a bit inside out as the legs are emerging, but that’s normal for newborn anatomy. That facilitates the legs being born. The legs flick out on their own and the shoulders come into the pelvis. You’ll see the “valley of the cord.”

You’ll see a crease in the chest (or "cleavage") indicating that the arms are close to the head and not to worry about. You’ll see the baby siting on the floor/birth bed. Don’t lift the mother’s buttocks and push the mother up at this point!

Sometimes women sit down a bit; this opens the pelvis and flattens the perineum, helping the baby come down. What’s happening inside the woman's body when she does this? At the top, this helps the baby’s head to flex. Do NOT push the mother's bottom up at your peril! (Unless you really need to get the baby out). Sometimes women will move, put a leg up, etc—let her do this.

Now the baby's legs are out and the shoulders are coming in. You’ll see the cord going up through the valley of the cord and going over the shoulder. The cord is quite protected and the baby is not pressing on the mother’s vena cava--another advantage of being upright.

Now with the shoulders, the baby continues to rotate to LSA, and that releases what was the posterior arm (now the anterior arm) under the symphysis pubis. The baby has done its own Loveset maneuver! That allows the posterior arm to drop down. With that, the head drops down into the pelvis. This is where you might get some cord compression.

Then, at this point, Jane and her colleagues had been watching women drop forwards (placing their heads near the floor/bed) and didn't know why. As they were watching photos and videos, they realized that babies are doing a “tummy tuck” at this moment. Often the baby's arms and legs move together, flexing and tucking. If this doesn’t happen at all, you might need to help the baby out. The baby lifts its tummy and arms, tucking its legs, and this movement brings the baby’s chin onto its chest and rolls the occiput onto the mother’s symphsis pubis. It doesn’t hurt the women, but they all say at this moment: “I had to move.” They drop their torso around forward and roll their pelvis around the baby.

Now all that’s holding the baby in is the pelvic floor muscles and the perineum. Plomp! Out comes baby.

Once the baby is born, follow the curve of the mother's sacrum and pass the baby through the mother's knees to the mother. Then, if needed, you can assess the baby from the other side.

The first Apgar score is taken at 1 minute. That can be a long time to wait. Breech babies are a bit like waterbirth babies. Leave them there. Don’t cut the cord! You still have the circulation going from the placenta. The babies will often lie there, quite happily, nice and pink, and then suddenly open up and breathe.

When the baby comes down LSA (about 45% of breeches), what you should be seeing for normal is mostly the same but on the left rather than on the right.

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Shawn Walker: Supporting breech birth within a paradigm of complex normality

First Amsterdam Breech Conference, Day 2

Shawn Walker, RM, MA, PhD cand.

Developing health professionals to support breech birth 
within a paradigm of complex normality

Shawn Walker is a registered midwife in the UK and a PhD candidate. She worked as a Breech Specialist Midwife in a NHS breech clinic and has attended births in homes, birth centers, and hospitals. Her PhD research focuses on upright breech birth.








Shawn opened her presentation with an extended analogy:

       In a parallel universe, imagine that 96% of babies are born bottom-first, and everyone knows all the variations of breech. Occasionally there are tricky situations and that’s where consultant OBs jump in.
       But then there are these 4% of babies presenting head-first that cause all sorts of trouble. Occasionally their heads come out and their shoulders don’t follow and panic ensures. And then someone gets the idea of having a term vertex trial, and it turns out the cesarean is safer than vertex birth. Gradually—because brachial plexus injury for shoulder dystocia is 1/20—cesarean becomes the standard of care for head-down babies.
       The occasional radical midwife makes trouble, suggesting that we go back to basics and look at the physiology of what happens when women direct their own births. Nope, OBs suggest it’s an obstetric issue; midwives shouldn’t be involved since they can’t provide the complete package of care.
       And then a very powerful and well-connected OB was having a telephone conversation and he saw a picture of someone doing axial traction to deliver the shoulders. He thought, let’s put women with vertex babies in upright positions where they can move and see what happens. And then another troublemaker in Canada proposed that midwives should be involved in vertex births because they have smaller hands and don’t even need to cut episiotomies. And so began the Small Hands Revolution!
       And then some researchers presented their data from all around the world insisting the data is clear that vertex is not as safe, but we must still have shared decision-making. And for that choice to be available, we must have access to the safest possible care. But we still feel vulnerable—how can we make it safer? Then a visionary said, “Look, it’s the 21st century. Birth is safer than it’s ever been—why can’t we do the same for vertex birth? How can we help each other feel less vulnerable?”

(If you hadn't noticed it already, Shawn just summarized Day 1 of the Amsterdam Breech Conference!)

Shawn then argued that there’s a paradigm shift going on to seeing breech as a complex normality, rather than an abnormality.

What is required to become competent in breech?
Shawn's recent article, Standards for maternity care professionals attending planned upright breech births (Midwifery Mar 2016) "establishe[d] a consensus of opinion on standards of competence for professionals attending upright breech births." The key elements are:

1. Hands-on simulation (skills and drills)
2. Regular opportunities to discuss with peers and mentors
3. Watching breech birth videos
4. Theoretical instruction in anatomy, physiology, mechanisms, and maneuvers
5. Mentorship and supervision in clinical settings

We can use videos of breech births to enable pattern recognition. What does that mean? When you attend a high number of births, you begin to recognize certain patterns. Shawn showed two side-by-side births. Both had good outcomes, with one being completely normal and the other right on the border of needing intervention.

We need to know what normal looks like (sternal crease or “cleavage," baby's body facing straight) versus what needs help (baby's body facing sideways).

Videos are great for practicing clinical decision-making. Shawn likes to play “save the baby.” Colleagues chime in while watching videos and say what should be done to help in a tricky situation. When you see signs of trouble--because you already know the signs and patterns of normal--you can then confidently step in and help a baby that can’t birth by itself.

Shawn also does Breech Study Days all around the world. Core elements of her physiological breech birth training include

1. Research updates—counselling is a skill
2. Teaching what is “normal for breech:” mechanisms, other features
3. Complicated Breech Births: skills and maneuvers
4. Simulations and case scenarios

When all is well, respect the mechanism

When all is not well, restore the mechanism

Shawn's online Moodle space facilitates great discussions among care providers all around the world and lets members share and compare videos. A new video is released each month to simulate the process of attending a breech birth regularly. Study Day participants get 1 year free access.

Shawn has also been evaluating her teaching, especially levels of confidence in her trainees before & after the training. She has found significantly increased confidence levels post-training.

We desperately need research evaluating real outcomes after breech skills training, not just confidence levels. She noted that PROMPT excludes outcomes of vaginal breech babies in their evaluation. Shawn will be evaluating this aspect from her recent training sessions in North America, doing a 1-year followup to see if there has been a change in behavior and outcomes, in addition to confidence levels.

Shawn also noted that obstetric emergency breech training does not lead to an increase in rates of vaginal breech births; it actually makes the rate go down. Can we make the rate of vaginal breech births go up? She’s also doing a visit to Auckland in the fall and collecting before/after data. She requested that if you’re doing breech teaching, please collaborate with hospitals to gather before & after data.

The most interesting question, Shawn remarked, is, Can we make breech birth safer?

~~~~~

Q from Andrew Bisits: Regarding the emphasis on mechanics, clearly I agree . It’s doable because we do and can understand the mechanics. However, the other part of making it safer is the oxygenation issue, particularly in the 2nd stage. There are unknowns in this aspect in how a baby copes. What are your thoughts about that area?
A: Regarding oxygenation and how we teach people how to evaluation fetal well being in 2nd stage and make decisions: when you’re a HB midwife and you start out, you have a higher transfer rate a the beginning. I maintain that 3-5 minutes from the umbilicus to birth is a great starting place (but it wasn’t approved by my consensus panel) because when you’re an expert, you have more intuitive knowledge and thus more time to play with. Novices need to be taught good methods: not to intervene too soon, but to be assertive with time if there isn’t clear evidence of good fetal well-being.

Q from a Dutch OB: It's really good for us to hear about your parallel universe and it made everything so clear at once. Two things about the videos: 1) cleavage: if you see the baby’s chest with a crease, that means the arms are close by and you just need to wait for another contraction. If you see a flat chest, you need to help the arms. 2) Meconium: not a sign of fetal distress in a breech. Tell your nurses and other staff there for the first time so they don’t worry about it. Be happy about the meconium—it’s a great sign in a breech birth.
A: Yes, in a full-day training course, that’s absolutely what we go over. Also tell your nurses, 2nd midwife, etc, that fresh mec is different from mec stained waters. Don’t document fresh mec as mec stained waters.

Q from Anke Reitter: Even if the baby seems to do all the right things, babies that have been compromised in 2nd stage will not help with the process and will look different (no tone, etc.). They need active hands-on. It’s like doing a cesarean on a baby with little or no tone.

Q: If you talk about making birth safer and about counseling, how do you involve the mother to make birth safer because she’s birthing her baby? How in your experience does it work better if the mother is fully involved?
A: You do have an obligation to share these numbers with them, though as Andrew Bisits remarked it can be complicated. As Floortje Vlemmix said, she asks women “What are you thinking about?” or “What do you know?” I also use videos to show women so they have an idea of how normal breech works. I also talk about what I'd do in complications and what I might say and what it means—so the woman understands beforehand.

Q: Do you find that if women have more confidence, it actually works better? Does her instinctive behavior help?
A: The movement to create breech specialist clinics is very very good. I will keep promoting that. I was a breech specialist midwife and I counseled everyone with a breech presentation. The women who’d come through my clinic chose VBB at a same rate as Dutch data (around 30 is %). Those women had easier births than women who came from outside with conflicted situations, who had to fight for their breech births. Sometimes they didn't know when to stop fighting. We should not make women fight for what they want.

Q from a Dutch obstetric resident: After hearing your alternate paradigm universe [in which breech is normal and head-down is uncommon], we are feeling so convinced to do it on all fours. Then we go out in our practice and we have colleagues who haven’t been to this conference. Should we try to convince our colleagues? No, instead we should gather together and carefully evaluate the short and long-term consequences of what we’re doing.
A: Definitely. To a certain extent, these techniques have been well-evaluated (for example, with Frank Louwen's study). Also, you cannot evaluate something until someone becomes competent in it--one of the problems with the TBT. Until you actually practice it, you cannot evaluate it properly. There’s a certain amount of latitude that experienced professionals have to say “This makes sense and I would like to try it.” You should certainly come together to help other people make those transitions, to help them get over the learning curve.

Q: May I add something: After this conference, we agree that the Netherlands is a small land. We can easily start here in Amsterdam. Our hospitals are on board to work together to help women to find the right place and to have those options. It’s easy to evaluate because you can do the births together and film them. We will do that here.

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Day 2 Welcoming Speech at the First Amsterdam Breech Conference

First Amsterdam Breech Conference, Day 2

Welcoming Speech

Ruth Evers

Courage is a quality of mind or spirit that enables a person to face difficulty, danger, or pain. Courage ins’t seeing what you want to see and proving to the world that you’re right. Courage is looking at all sides of the matter and being brave enough that you realize you might need to change your ways because you allowed yourself new insights and a new paradigm.

Thanks to Gail Tully showing us videos of breech births that were not so easy. Thanks to Floortje Vlemmix for talking about subsequent births after the breech birth and for acknowledging that we’re not so sure what’s right and what’s wrong. Thanks to Frank Louwen for telling us that almost everything we do in daily practice is outdated and that putting women on their backs is an intervention.

Today we’re going to build courage as we do hands-on training and learn how to do a breech birth on all fours.

Ruth concluded her introduction with a brief excerpt from the documentary A Breech In The System.

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Expert Panel Q&A at the Amsterdam Breech Conference

First Amsterdam Breech Conference, Day 1

Expert Panel Q&A

Q: I have a question about the article by Thornton et al, referenced by Floortje Vlemmix, that argues that cesarean for breech is clearly beneficial. I have a question about some of the data.
Betty-Anne Daviss answered. (I didn't catch all of her answer, but she discussed the Canadian registry study.)

Q: I have a question about the experience levels of OBs or midwives doing vaginal breeches. Most guidelines suggest experienced practitioners. What do panel members define as experienced? Any factors/parameters that qualify?
Frank Louwen: You have to attend some VBBs, but initially you should watch videos over and over. This is more important than just attending the births. Watch videos: not just the last 10 minutes of the birth, but from the beginning of the labor.

Q: You have to attend many VBBs to be able to identify pathology.
Frank Louwen: We’re always seeing CS and VBB compared without a closer look at the vaginal breeches. What is a real risk for VBB? Once we can point those out, then we can really reduce mortality and morbidity. I've been able to reduce complication rates by more closely looking at the woman and child.
Rebekka Visser: There are cultural differences in hospitals in how they do breeches. For example, what about shoulder dystocia? Some providers have higher instances than others, which points to the complications arising, in part, from what providers are doing. Numbers don’t say everything.
Marjolein Kok: Not many people can speak of real experience here in the Netherlands. You need to know how to solve problems. How? Practice on a mannequin.
Betty-Anne Daviss: We should do a randomized controlled trial on the effects of fear. Fearful people do very crazy, dangerous things. In Canada, we have a 10-15 year break in OBs who used to do VBB, stopped doing it, and then just started doing it again. So they are very fearful because they haven’t done it for a long time, and they act based on that fear. How does fear affect clinical practice?

Q from an OB: Nowadays women are so fearful and anxious to choose a VBB because they worry about regretting it afterwards. How can we counsel women so they have more trust in delivering safely with a VBB? Use other language? Other suggestions how we can counsel women better so they don’t make decisions out of fear or regret?
Andrew Bisits: We do present numbers, but we also are dealing with a generation of women who’ve never been healthier. I’d say this to a woman with a breech baby: “I am confident that I think it would go well for you.” It’s unfortunate that there’s such a fear when, really, whatever we do is safe. We’re dealing with such small numbers now. We’re not going to have a hope in hell unless we do address that. We ourselves need to reclaim confidence in our own skills.
Leonie van Rheenen: Many women have already made their decision by time they come in to see us. Maybe we need a Kim Kardashian who’s done a VBB!

Q: I’m an OB. I've done over 3,000 cesareans and just about 100 VBBs. I am scared with VBBs, even though I do support that choice. Do you support that quote I asked about earlier? (I think he was referencing Thornton et al.)
Frank Louwen: If I had the complication rates reported in the TBT in my own clinic in Germany, I wouldn’t work anymore. I’d be in jail! I am completely convinced that just giving the women the information about the TBT—that they compared different settings, situations, etc—will show that the cesarean was never an answer to complication rates in breech deliveries. It’s not an existing answer for our counseling of women. In Germany, we don’t understand why people are still looking to that trial, as Marek Glezerman pointed out.

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Thomas van den Akker: Who pays the price? (Foreign) women, future siblings

First Amsterdam Breech Conference, Day 1

Thomas van den Akker, MD PhD

Who pays the price? (Foreign) women, future siblings

Thomas van den Akker, MD PhD, is an obstetrician at Leiden University Medical Center. The slides from his presentation are available here.

Of all the presentations during the 2-day-long conference, Thomas van den Akker's was the most powerful and most memorable. Future siblings and foreign women are now paying the price for Western countries' fear of breech.

Thomas opened with the comment that “not every breech delivery is a hallelujah delivery.” He doesn’t have a clean record like Dr. Frank Louwen. But he’s still here to defend the option of a vaginal breech birth. His only conflict of interest is the woman in a faraway land who might pay the price for our fear of the breech.

He’s not a fan of the 2000 Hannah Term Breech Trial because it has a flawed data set. But assuming that the TBT is true and not flawed, what are the outcomes of a policy of universal cesarean for breech presentation? For term breech babies in the Netherlands, the Number Needed to Treat (NNT) comes to 338 based on a 2014 study by Vlemmix et al. In other words, doctors needed to perform 338 cesareans to save one breech baby’s life. However, looking only at these numbers is shortsighted (for one example of shortsightedness, he pointed to this 2015 article by Joseph et al in Obstetrics and Gynecology).

What do you miss when you only look at the NNT?

1. The mother
2. Subsequent pregnancies
3. The rest of the world—much of the rest of the world is really missing from the conclusions and ramifications of the Term Breech Trial, such as remote hospitals far away from urban centers.

These three questions are hard to answer because there’s under-reporting of adverse outcomes, limited and/or little long-term follow-up on the mothers and babies, and fear of litigation.

The TBT gives a very limited answer about maternal morbidity.

Figures from the Netherlands give us a better look at how a policy of cesarean affects women. These figures are clear: severe acute maternal morbidity is higher with cesarean section than with vaginal breech birth. Peripartum hysterectomy is higher in the cesarean groups. (See Van Dillen et al. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstetrica 2010).

Between 2000-2002, four Dutch women died after having an elective cesarean section for breech, which comprised 7% of the Netherlands’ direct maternal mortality. (See Schutte et al. Maternal Deaths after elective caesarean for breech presentation in the Netherlands. Acta Obstetrica 2007.)

Thomas reiterated that if we do a lot of cesareans, some women are going to die from them. Others will be injured in the short term.

There are also long-term consequences from cesarean sections for breech. Maternal morbidity in subsequent pregnancies is higher.

Perinatal death is subsequent pregnancies is higher.

Again, from the Dutch data, for every 10,000 babies delivered by elective cesarean section for breech, 26 will be saved in that pregnancy. But...27 babies will be lost when the woman has her next baby, assuming a policy of VBAC. 

This raises an ethical question: Does performing 997 elective cesarean sections justify saving the lives of 3 babies? What about the costs?

In our context (resource-rich, developed world, easy access to hospitals), the difference in outcomes for a mother's first child is small. But there are enormous consequences of a cesarean-only policy in other parts of the world.

Remember the NNT of 338? (338 elective cesareans for breech presentation needed to prevent one fetal death.) In other parts of the world, the dangers of cesarean sections are amplified. In Tanzania, those 338 cesareans would result in 6 maternal deaths. In a district hospital in Malawi, 3 women would die for every one baby saved. And that’s just in the short run. (See Van Roosmalen and van den Akker BJOG 2014 and Van Roosmalen Lancet 2014).

In addition, fertility rates can be much higher than in the Western World, so the impact of that cesarean section for breech is multiplied.

Thomas concluded that our messages about breech are doing harm elsewhere. We need to take into account a woman’s complete fertile life, especially if she’s living in more dangerous circumstances where cesareans are much less safe than they are in developed countries. Dealing with a breech is not simply black and white.

~~~~~

Q (Australian OB Andrew Bisits): Women have difficulty processing these numbers, but even for us OBs it’s difficult. How do we know that what we are presenting is comprehensible? Women are processing not just the numbers, but a whole lot of other factors that go into their decisions.
We’re dealing with very small numbers of adverse events. We should at least be able to learn something from the adverse events to make things even safer.
A: Yes, agreed completely. We should take into account adverse events, but in a much wider context and setting. We need to give the other numbers—the ones I presented today—to confront people pushing ECS for all breeches.

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Lester Bergenhenegouwen: Optimal mode of delivery in preterm breech presentation

First Amsterdam Breech Conference, Day 1

Lester Bergenhenegouwen

Optimal mode of delivery in preterm breech presentation 

Lester Bergenhenegouwen, MD PhD, is a gynecologist at ZGT Hospitals, Albelo and Hengelo, in the Netherlands. She did her PhD research on breech, twins, and triplets. She began her presentation with some statistics about the frequency of breech presentation at various gestation points. The optimal mode of delivery for a preterm breech baby is a subject of debate.

No large RCTs exist on this particular topic—all were stopped due to recruitment difficulties. She helped author a systematic review of relevant cohort studies (Jan 2014). Her review found that cesarean section for preterm breech babies reduces neonatal mortality. However, the studies lacked intention to treat analysis and had other biases inevitable in cohort studies.

Lester also did a study of preterm breech singletons using the Dutch birth registery (Dec 2015). She found that planned cesarean section "was not associated with a significant reduction in perinatal mortality compared with intended vaginal delivery. However, the composite of perinatal mortality and morbidity was significantly reduced in the intended cesarean delivery group." For babies at 28-32 weeks gestation, planned cesarean section shows the most benefit.

Lester reiterated that the lack of large RCTs is still a major issue in studying preterm breech birth. Planned cesarean section brings some benefits to babies between 28-32 weeks, but the overall effect is small. The major risk from the preterm births is from prematurity, not from the breech presentation. The additional risk of vaginal breech birth is minimal.

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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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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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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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