Tips & Techniques for Vaginal Breech Birth: Heads Up! Breech Conference

Day 1:

Michael Hall

Vaginal Breech Birth: Tips & Techniques

Dr. Michael Hall has lived through several major shifts in obstetric practice. When he trained several decades ago, he learned all sorts of skills that are dying out—vaginal breech, forceps, and more. They didn’t do c-sections for breech. Everyone did VBACs; it was actually a requirement for a period of time. Then he lived through a huge shift in practice where almost everyone had c-sections. Now he’s seeing the pendulum swinging back toward keeping vaginal skills (forceps, breech) alive. He passes his skills on to the students he trains, but he just doesn’t have the population base to train enough people at his own hospital. That’s why he has since set up a breech unit at the local university hospital.

Dr. Hall’s selection criteria for VBB:

• Because he uses pretty strict criteria, it’s kept him out of trouble. Physician colleagues who’ve gotten burned with breeches often have done things outside of a reasonable criteria.
• EFW 2000-3800 g
• Frank or complete breech (he’s found that complete breeches have a larger bottom diameter and thus the head is easier to birth than with a frank breech)
• Adequate clinical pelvimetry: do a good pelvic exam; you’ll know by experience if a pelvis is small or abnormally shaped
• Flexed head (i.e., no hyperextended head)
• Follow Friedman’s curve: for a breech, you want a normal, consistent labor pattern. The ones that slow down make him nervous. For induction or augmentation, he never goes above 6 ml/u, which is what simulates a normal labor pattern. You don’t push your limits in a breech. Once they’re in labor, he usually turns the Pit off.
• Experienced operator (skilled with forceps). He’s only had to do it 4 times in 31 years with hundreds of breeches. It’s a last resort, but an important skill to have.
• Informed consent. The biggest thing (he wants the husbands to be aware of especially) is that sometimes babies are breech for a reason and will have problems no matter the route of delivery.

The way to birth a breech is to leave it alone. He has the mother do all the work. You have about 4 minutes to get the baby out once it’s born past the umbilicus, unless the baby still has blood circulating through the cord. He rarely helps reduce the legs; they almost always do it on their own. If you get a nuchal arm, you need to know how to help the arm come down. Most of the arms will come on their own if you let the mother push the baby. That takes patience and sitting with your arms crossed! You have do things gracefully. If you’re struggling, you’re doing it wrong. Keep the baby in line. Be firm but gentle. The mother can push the baby out in line; we’re the ones that take it out of line. (By “in line,” he means never move the baby or the head laterally. You want the spine and the head to always be in line with each other.)

Maneuvers:
In certain cases he does “finger forceps” (deep perineal massage). He thinks this helps the head emerge more easily. He also thinks it helps women push better if they’re having trouble focusing their efforts.

He’s never used Mariceau-Smellie-Veit much himself. He has 2 other tricks to get the head out:
1. Have someone lift the baby up slightly to do finger forceps. Put your fingers inside and stretch and pull to make more room for the head to come out. You have to get in deep and push down on the leveators. What’s important is that downward descent: even an extra ½-1 cm will make all the difference
2. Apply gentle suprapubic pressure to ease the head out gently.

When the head is emerging, avoid over-extension of the baby’s body (if the mother is on her back).

Sometimes babies can aspirate matter as their faces emerge. Keep an eye out for that.

Pipers forceps are no more difficult than an outlet forceps. If it’s a struggle, you’re doing it wrong. You slide the lower blade in first. He always keeps them ready, even though they are rarely necessary. Follow the curve of the pelvis with the blades. He’s never had a head get stuck that wouldn’t come out.

Do an ultrasound before labor and check for hydrocephalus or other neurological issues. Know your patients.

Low 1 min Apgars aren’t uncommon; have Peds present.

He’s seen some prolapsed cords—2 in the last 50 breeches.

He tells all his women planning VBB that they have to exercise and work out. They need to be in shape so they will have the endurance to birth their babies.

Hands and Knees:
After the last conference, Dr. Hall started doing H&K births. He finds them a whole lot easier than on-the-back breeches. You do much less maneuvering on H&K.

The baby comes out Sacrum Transverse. It then rotates to face you (Sacrum Anterior) when the woman is on H&K. The butt goes straight down and gravity helps it emerge. The baby will reduce its own legs. After that point, gently check the cord to see if there is still blood flow. At this point, strongly encourage the mother to push. Do not pull on the baby. Remember: push, but not pull. The arms will usually come out on their own. After the baby is out to the shoulders, here’s another trick: take gentle thumb traction and put it on the clavicles, then press directly backwards. This flexes the head. (This is also known as “Frank’s nudge.” Some people apply subclavicular pressure; others apply it to the shoulders.) You push straight back on the clavicles, not pull down. Be gentle.

His very first experience with breech was during an externship; a woman came in and delivered a breech on the way to the delivery room while everyone else but him was gone scrubbing in. It went really easily and set the course for his attitude about breech.

What if...real life situation...a 32 year-old G4P3 arrives in L&D in transition. Upon inspection, you discover feet hanging out. It is a double footling breech. What do you do? The OR is in use with twins. Anesthesia is staring at you, expecting to do a crash section. The head nurse is staring at you; she does NOT want a crash section. The patient is screaming for you to “take it OUT!” Anesthesia is still staring at you. What do you do?

Take a deep breath. Take 30 seconds to take in the scenery (assess pelvis, check for cord, get the Pipers, get Peds). Tell her to PUSH! If they’re coming that fast, they’ll probably be fine. Doing a crash C/S often will do more harm then going ahead with a vaginal birth in this situation. The nurse came up and thanked him afterwards: “That could have been a disaster.”

You have to be comfortable working with breeches; you also need to be smart.

Term Breech Trial
He discussed the TBT quickly, because it will be covered in other sessions. He’s seen so many pendulum swings during his career that it’s not even funny. He’s always just kept on doing breeches. He discussed the current situation in the US, the recent ACOG recommendations, and problems with the TBT. Evidence-based medicine in obstetrics is just about impossible to do; most things are observational. The TBT failed to appreciate the complex nature of VBB and the complex mix of operator variables necessary for its safe conduct. VBB is operator dependent; he doesn’t let some of his residents do it because they’re klutzes! The safety of vaginal breech is dependent on the skill level of the attendant. The most difficult part is determining when you need to do something and how fast to do it. You have to move “deftly.” You have to know when to move and when not to move. Those issues cannot be randomized. The TBT had many issues complicating the study, pushing practitioners beyond safe limits. The reason that an experienced OB won’t do a breech—even one that’s as picture perfect as you can get--is liability reasons.

The ACOG’s current guideline on breech states: If you’re experienced, it’s OK. The guidelines also note that we are not training OB residents in forceps or VBB. Those skills are becoming a lost art.

Safe vaginal delivery depends on skill in multiple areas :

• Delivery technique
• Use of forceps
• Ultrasound assessment for presentation, head flexion, & major anomalies
• Selection of cases—not everyone is a candidate
• EFM during labor
• Conduct of labor
• Pediatric support
• A coordinated, well-functioning L&D unit; be prepared

He does breech-first twins. A study concluded that if the operator is experienced, then a vaginal birth of breech-first twins is a safe option.

Above all, you need to think. You can’t just say “it’s a piece of cake.” Most of them are, to be honest. But always keep a sharp eye out for odd things.

Women want choices.

Q: If the baby is not directly SA, do you rotate the baby?
Q: Can you tell us about difficult breech scenarios?

To answer these questions, Dr. Hall showed two breech videos from his practice. The 2nd video showed a baby with nuchal arms; the mothers was on H&K. After the baby’s body emerged, it did not rotate back to Sacrum Anterior. Instead, it remained around 45 degrees from SA, indicating one or more nuchal arms. You reach in with the hand that’s towards the back and gently push/sweep it across. If it’s not coming easily, you probably need to get some other position. If the other arm is still trapped, you can rotate the baby 180 degrees; the arm will often come out on its own. Then you rotate the baby back to SA. When a mother on H&K drops her chest or lowers her bum, the pelvis opens naturally. The baby often lifts its legs up and flexes its own head and comes out on its own. If that doesn’t happen, gently push on the clavicles with your thumbs to flex the head. If you’re having trouble, have the mother lower her butt towards you. His H&K deliveries tend to come out so fast they fall out; his nurses are getting really comfortable doing them now.
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International Perspectives on Breech: Heads Up! Breech Conference

Day 1: 

Panel on International Perspectives

• Jane Evans (Independent Midwife, UK)
• Andrew Bisits (OB/GYN, Australia): has attended over 300 VBB, planned and unplanned, since 1990s?
• Marek Glezerman (OB/GYN, Israel) 
• Anke Reitter (OB/GYN, Germany)
• Michael Hall (OB/GYN, USA) 
• Moderator: Betty-Anne Daviss (midwife, Canada)

Each panelist talked about the breech climate & protocols in their own country.

Jane Evans: UK

Once the Hanna Term Breech Trial (TBT) trial was released, it took away women’s choice of a vaginal breech birth (VBB) in the UK with “horrendous speed.” Gradually over the last 12 years, women have been saying no to cesareans and turning the tide. Still, women's choices are mostly to have a cesarean at a hospital or to have a VBB at home with a midwife. There are some small outposts within Scotland, Wales, and Northern Ireland where hospital providers still have vaginal breech skills. But breech is politically very delicate right now. In England, there are 1 or 2 isolated units where VBB was continued after the TBT, supported by brave obstetricians. We are left with a nearly 100% c/s rate for breech in most hospital units within the UK. In the last few years, a few forward-looking units have started to set up breech clinics. These were supported by midwives and gradually received more support from OBs. That has nudged other OBs into being more open to VBB.

Today there is a small groundswell for VBB because of the observational research coming out on VBB and on the research about the risks of a high cesarean (CS) rate. We may be able to start developing more choices for women with babies in the breech presentation. For example, there’s a unit in Yorkshire with a skilled midwife; this unit receives breech referrals from the local OBs. There’s a breech clinic set up in Norwich and another in Scotland. We will need a lot of time to develop the skills needed for breech birth. It’s more hopeful in the UK than it was 3 or 6 years ago, when the first two breech conferences took place.

Jane works as an independent midwife. Because IMs have no malpractice insurance, hospitals have withdrawn privileges, which means the more skilled midwives have to transfer care to a less skilled provider if the woman wants to birth in a hospital. But largely the choice remains a CS at a hospital or a VBB at home.

Andrew Bisits: Australia

He was invited to participate in the TBT. He spearheaded a move to increase the numbers of VBB so they’d have sufficiently skilled providers for the trial. He was very skeptical when Mary Hannah read the protocol to them. He strongly felt that the TBT was not the best test for determining the feasibility of VBB. There were 6 participating centers in Australia. After the TBT, VBB was no longer an option in Australia. Everyone lost their skills "overnight." It came at a time when many legal pressure were mounting. There was a $12 million payout to a Cerebral Palsy baby, combined with other concurrent events, that led to a “hysteria” about the obstetric situation among OBs.

In this climate, the TBT emerged. The RANZCOG then advised the majority of women to have a CS, saying that some might choose a VBB—in reality, this meant that all women would have them. In 2006, RANZCOG revised their guidelines (PDF here) to be less restrictive. Dr. Bisits was called “mad” for doing VBBs.He commented that Marek Glezerman’s 2006 article Five Years To the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial in the AJOG “saved my ass.” (Full-text PDF available here.)

From 2000-2010, Newcastle John Hunter Hospital was the only in the country to offer VBB. Why? Some women strongly wanted it, midwives were keen to do it, and it provided an “important insight into normal birth. If we lose that, we lose an important source of insight in our training.” Continuing to offer VBB also served as an important antidote to the medicolegal anxiety which dominated obstetric practice in Australia. It was just too important, at his hospital, to give up VBB. It was an important exercise in watching these women engage and deal with the risks.

Recent developments in breech research and training
The SOGC's 2009 revised statement (PDF here) had a “very significant” influence in Australia. Dr. Bisits finds it a useful counseling aid for himself and his hospital. In 2010, he moved to Sydney for family reasons. He started a breech birth service at the Royal Hospital for Women. There was resistance from the OBs, but marked enthusiasm from medical trainees and midwifery staff. In 2011, another teaching hospital has started a breech clinic under Dr. Andrew Pesce and midwife Michelle Underwood. Now RANZCOG is proposing breech training workshops to re-skill obstetricians. This was supported in part by a dangerously difficult CS in which the woman died; she had a breech baby, was fully dilated and ready to push, but not allowed to. This unfortunate event played a significant role in shifting attitudes towards vaginal breech birth.

Now in 2012, there are a number of “born again breech enthusiasts” who recently advocated for VBB in the RANZCOG journal. Women's Healthcare Australia has organized a breech conference on Nov 30 2012 at the University of New South Wales, with over 100 people already signed up to attend. On day 2, there’s a breech skills workshop. They’ve also completed an audit of breech births in Newcastle from 1999-2010, which he’ll discuss in more detail this afternoon. There are planned ongoing breech workshops through ALSO and more positive emphasis on VBB in medico-legal seminars. He also mentioned some ongoing qualitative studies examining the experience of women embarking on a VBB.

In sum, VBB is now offered in 3 major teaching hospitals in Sydney. He hopes that a similar service will be established in each of the other capital cities. There’s an emphasis on detailed training using good birthing models (simulators). He noted that consumer and midwifery energy has driven most of these changes. It’s also been fueled by more research highlighting the importance & value of normal birth. Obstetricians are remain apprehensive about VBB, while midwives and medical students are more enthusiastic.

Marek Glezerman: Israel

Dr. Glezerman recently brought the Frankfurt team to his hospital in Tel Aviv, the Rabin Medical Center. It has 9,300 births/year.

You can’t talk about general percentages of VBB in Israel, because it varies widely between cities and hospitals. In Israel, there are 25 medical centers that have maternity wards, and they all track their obstetric statistics. One hospital in Jerusalem had a 38% VBB rate, but it closed last year. His hospital has a 14% rate of VBB. On average, the VBB rate was 7.4% for 2010. It’s about the same as at 2003. There was a decline through 2006, but then a rise after that.

When he was approached to join the TBT, he was enthusiastic about having a RCT. He was at Wolfson hospital at that time. He also got another hospital on board. When it slowly appeared that the TBT was on a wrong path, he felt somewhat responsible for the involvement of Isareal’s centers. He went out and gave talks about this; it helped to move the VBB rate up in the later 2000s. The rate of vaginal breech birth reached a peak in 2007 and 2009. Now it’s been declining in the past few years. It’s a question of politics, of being convinced about something, of geography, and of the people involved. He’s had to reconsider the strategies he was using to get hospitals to come back on board.

He lamented that there’s no discussion about the pitfalls of the TBT. There’s no discussion of VBB in the right setting being a good option. It’s like a power plant: everyone wants light and electricity, but no one wants the power plant in their backyard! Everyone might agree it’s a good idea, but hospitals are reluctant to be the ones offering it.

What tools should we use in trying to convince hospitals that VBB is a good option? 
Emphasize that we’re always comparing risks with risks, not risk vs. no risk. You also need to think of the woman’s future pregnancies, not just this one, when deciding between a cesarean and a VBB. We also need to focus on the risks involved with C.

Looking at the numbers of cesareans done in Israel in 2011, 15% of CS were due to malpresentation (most of those for breech). 37% of CS were due to a previous uterine scar (most were a previous CS, with a few myomectomies). A lot of that 37% were due to an initial CS for breech presentation. Overall, about 40% of CS in Israel are done because of past or present breech presentations. We need to stress that point.

Dr. Glezerman next discussed ISOG's (Israel Society of Obstetrics & Gynecology) evolving position papers on vaginal breech birth. He and some colleagues helped rework and revise the recent position paper. It recommends:

• “VBB should be offered as an option to carefully selected women under defined circumstances.” This also means that someone should be around who can offer it. 
• “ECV should be considered.”
• “Parturients should receive extensive information and give written informed consent. A senior obstetrician should be responsible for evaluation and delivery.” (In Israel, midwives cannot deliver a breech at hospital or at home.)
• “A pediatrician and anesthesiologist should be available at delivery.” (Not necessarily in the room, but on the premises)

This might seem a far cry from what should be the policy, but it’s the best they could get. At least now they have this position paper. It’s the major safety net for OBs performing a VBB if it comes to a medico-legal issue.

He wrote a recent commentary To rescue a vanishing obstetric skill--vaginal breech delivery in the journal Harefuah. 

Contraindications to VBB:

• EFW < 1500 g or > 3800 g
• Footling/incomplete breech
• Hyperextension of head (by ultrasound)

Considerations:

• Induction is optional
• Primiparity is not a contraindication (it used to be—there was a huge fight over this)
• Prematurity is not a contraindication

Dr. Glezerman acknowledged that some of these guidelines might seem overly restrictive, but tehy at least open the door for VBB. Once vaginal breech birth is well established, we may be able to loosen the guidelines somewhat. But we can’t risk a bad case right now; we need to ensure that we have a very selected group of women likely to have good results.

Importance of simulation-based training
Simulation training is used to train physicians in many medical and surgical fields. We need to implement simulation training for VBB too. Anke Reitter and Betty-Anne Daviss did a course on VBB using simulation training; 22 of the 28 residents at his hospital attended.

Dr. Glezerman ended his presentation by showing a pictures of the first H&K delivery at his hospital. Anke Reitter and Betty-Anne Daviss were present for the birth.

Before the next speaker, Betty-Anne Daviss added that Marek Glezerman and Frank Louwen took a huge amount of heat from skeptical obstetricians in Israel. We owe Marek a big congratulations for his efforts. She then introduced the next panelist, Anke Reitter, commenting that she had searched all over Europe for a unit doing vaginal breeches in an innovative fashion and became "glued" to Frankfurt once she found it.

Anke Reitter: Germany

Anke Reitter started her training well before the TBT and did a lot of VBB in Britain in a big unit in Liverpool. She often had undiagnosed breeches coming in. At the time, it wasn’t a big deal; she was trained from the senior OBs with no fear. When she came back to Germany, the TBT came out and everything had changed. VBB was rarely, if ever, done.

However, she noted that demand for breech and vaginal twins are coming back; as obstetricians we must be well-trained and train our juniors.

Contraindications to vaginal breech birth in Germany: 

• IUGR
• EFW weight > 3800 g (*she doesn’t at all agree with the 3800 g cutoff. She has found that the bigger the baby is, the easier it is to birth)
• disproportion (unclear whether this meant pelvic disproportion or head/body disproportion in the fetus)
• footling breech
• pelvic anomaly
• inexperienced OB

German guidelines dating August 2010 recommend: 

• ECV should be offered and must be part of special obstetric training 
• Clinical assessment of pelvis; MRI or x-ray not essentia
• do an EFW (“highest chance for a successful VBB will be in a normal size baby) 
• Unit should have an experienced OB on site, plus neonataoloigst and anesthesiologist (She asked *how many does this mean? How often? What does experienced mean?) 
• Prenatal counseling and information about the unit
• Informed consent for VBB

In Germany, ECV is done starting at 36 weeks. They use no tocolytic drugs or anesthesia for the procedure.

Pelvic MRI
In Frankfurt, every primip receives a pelvic MRI. An obstetric conjucate of  <12 cm leads to a planned cesarean. Primips with an obstetric conjugate of >12 cm can have a trial of labor. They don’t look at any other parameters other than the obstetric conjugate.

The Frankfurt clinic does a lot of primip breech births: 70% of their vaginal breech births were with primips.Their numbers of vaginal breech births have doubled since 2004. A lot of women travel to their clinic to have a breech birth. They are an island in how they approach breech birth. In many other hopsitals in Germany VBB isn’t really an option. Because of that, they’re very exposed and have to adhere to relatively conservative guidelines.


Dr. Reitter showed this flow chart for her unit's exclusion and inclusion criteria:

Women who fall into the following categories require a prenatal work up:

She compared her unit's outcomes to the PREMODA and Dublin data. You'll notice that the Frankfurt clinic has a higher rate of planned VBB and a lower rate of successful VBB than the PREMODA study. Overall, however, a greater percentage of all women with breech presentations in Frankfurt have vaginal births.

If a woman plans a cesarean section for a breech presentation, they prefer to wait for labor to begin spontaneously or until around 40 weeks.

Women who live far away continue their prenatal care with their normal midwife or OB, then come back to the Frankfurt clinic during labor. They prefer for labor to begin on its own, but they may induce at 10-12 days postdates.

To conclude, Anke Reitter expressed her committment to physiological breech birth. Like Eric Bracht, she and Dr. Louwen "do not want to disturb the physiological process of a vaginal breech birth, we in fact want to support it.” From the hundreds of upright breech births they have done int he past decade, they conclude the following:

Our hypothesis is that the maternal position during labour impacts on the natural descent of the fetus, on the necessity of using manoeuvres or interventions, and on maternal and fetal outcomes. 

Take home messages:

• Upright position does expand the pelvic [dimensions] and therefore will facilitate labor and delivery
• This advantage should be used in all deliveries
• In pregnant women with normal pelvic measurements, a vaginal breech birth does not lead to any increased risk for mother and child

Michael Hall: USA/Colorado

There were only three minutes left in the session when Dr. Hall began speaking, so he had to abbreviate his comments.

Michael Hall, an obstetrician in the Denver area, expressed his frustrations that he couldn’t get ACOG representatives to attend this conference, despite extensive efforts by him and other physicians. He is a fellow of ACOG but not spokesman for the organization. He’s in the trenches, not an academic OB/GYN. He has recently received privileges at a teaching hospital in Denver so he can start teaching the residents vaginal breech skills. It took a year to get privileges.

He has met a lot of resistance from his peers about attending vaginal breech births. Pediatricians are particularly resistant to VBB, since breech babies come out needing assistance more often than vertex babies. However, he keeps on doing it and doing it. Now his local hospital is comfortable with it. His nurses now are very comfortable with VBB and very respectful of him. But it’s a long process to get there. It’s not whether or not we can do VBB. We can do it. Most of obstetricians know how to do it. But many don’t want to. If they see some of their peers doing it again, then we can make some inroads.
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Breech Conference Highlights

It was an exhausting, exhilarating three days at the 3rd International Breech Conference in D.C., sponsored by the Coalition for Breech Birth. Our schedule was packed from early morning until late in the evening.

It's amazing to see the developments since the last breech conference in Ottawa in 2009. Three years ago, Dr. Frank Louwen and Dr. Anke Reitter had just introduced their pioneering work doing upright breech birth in a hospital setting. Today, they presented the results of 900+ breech presentations at their clinic from 2004-2011. They've done a preliminary analysis of the data and hope to publish it soon.

Three years ago, obstetrician Michael Hall of Colorado first learned about hands & knees positioning and said, "That sounds really interesting; I'd like to give it a try." Now he's doing lots of upright breeches and has found that they require much fewer maneuvers.

Three years ago, Ottawa midwives were required to transfer care for a planned breech birth, even though doing breeches was within their scope of practice. This meant that some very experienced midwives had to transfer care to less experienced physicians; they could stay in the room but could not assist with the birth in any way. This also meant that some women ended up with cesareans if no physician willing or experienced enough was on call. Just this week, Montfort Hospital agreed to waive the mandatory transfer of care policy, becoming the first hospital in North America to allow midwives to attend breech births as the primary care provider.

One of my favorite things about this conference was seeing experts in breech birth from around the world hammering out the intricacies of how a breech baby navigates through the maternal pelvis, asking questions and challenging each other on their research and outcomes, and collaboratively building a new body of knowledge.

I'll continue to post my summaries of each conference session that I attended. Keep in mind that some of them will be less coherent than my usual posts; I was trying to capture as much information as possible. I also have some selected videos I hope to share: Dr. Michael Hall sharing tips & techniques, UK midwife Jane Evans demonstrating the cardinal movements of the breech, and more.

I met some amazing obstetricians, some of whom I'll introduce later in my conference notes. They're doing vaginal breech births, VBAMCs, water births, opening birth centers, and fighting to get midwives hospital privileges. They're working to re-train other obstetricians in how to attend breech births and gradually overcoming resistance from their colleagues. I've invited some to write guest posts and hope to share those with you soon!

And of course I can't forget to mention all of the other fantastic people I met or reconnected with. There are too many to name here, but please keep in touch. 

Best of all, I came back to my hotel room before heading to the airport...and there was a woman in labor! (I was rooming with Canadian midwife Gloria Lemay, and she generously offered our room to the birthing family.) I packed as quietly as I could and whispered good luck wishes on my way out. Only at a conference like this...
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Robin Lim: Heads Up! Breech Conference

Day 1: 
Robin Lim: Birth on the Edge

Robin Lim was last year’s recipient of the CNN Hero of the Year Award. Her presentation was a moving series of stories from her work in Indonesia and other countries. I've tried to type up as many as I can.

Women in Russia are coming to Bumi Sehat, the birth center in Bali Robin helped found, to have their babies. Hospitals in Russia separate women from their babies for 5 full days and nights before they are allowed contact. She spoke of a mother whose daughter was born in Russia with the 5-day routine separation, then who had her son at Bumi Sehat.

Robin started a SE Asia Waterbirth Association. She’s seen women traumatized by the tsunami get into a birth tub—their first voluntary contact with water since the tsunami. Balinese OBs have recently decided they will not do water births.The Bumi Sehat midwives have decided to make a stronger informed consent process and keep doing it, rather than cave to OB’s pressure. Private hospitals have 80-90% cesarean rates; public hospitals (for the poor) are up to 40% in many areas. Because of this, Bumi Sehat does VBACs every week, sometimes 2 per day.

She’s a citizen of the US and former resident of the state of Iowa, where it’s a felony to be a direct-entry midwife. There are 3 main groups in Iowa who choose home birth: Amish, Mennonite, and some transcendental meditation groups. These groups have had fatalities because they’ve chosen home birth but could not find a midwife, thus leading them to birth unassisted.

981 women die every day worldwide of complications of pregnancy and childbirth. Most die, ultimately, from poor nutrition. The leading cause of death in her island has become PPH, which she ties to the dietary change from brown rice to while rice. The main source of protein in Indonesia is tempeh (from soy, which is now all genetically modified). She’s seeing an increase in retained placentas and abnormal placental situations which she attributes to the GM soy. 

Do they do breech birth at Bumi Sehat? The official answer is “Are you kidding? It’s against the law.” In reality...well, they do quite a number of breeches. The midwives at Bumi Sehat believe that the family should make the decision of what happens, not the care providers. But they also have to walk the line so they can keep the clinic open.

Her sister died as a complication of her third pregnancy. No midwife would take her because of her large size. She was feeling very unwell, and her OB said to wait until her next visit. She died in her sleep. Her sister is on Ina May’s quilt.

We midwives know that love is a nutrient. How else could we take care of undernourished women and help them do so well? How did we in Bali get away with what we do? (Very delayed cord cutting  or lotus birth, etc.) How did the Dept. of Health allow this? Her friend Mary Kroger taught her to speak to doctors and the health department with love, not anger. She spoke about an OB who used to be hostile to her, but now who is a “reborn gentle birth guy.” He’s head of obstetrics at a big teaching hospital and has become a revolutionary in the birth world.


Her favorite breech story: 14 years ago, Robin was a new midwife. She had just fled to the Philippines after the political changeover in Indonesia. A woman randomly walked up to her door with a limp cord hanging out from her. The baby was transverse, and she could hear no heartbeat. Robin tried to turn the baby, and it flipped to footling breech. It was born pretty quickly, the flattest baby she’s ever seen. Robin started doing neonatal resuscitation. There was no heartbeat, no respiration, but she felt the baby was close by. The woman’s grandmother had told the pregnant mother that if she didn’t allow this baby to be born vaginally, the baby would not make it (The woman had had a cesarean section for her first baby due to breech, then 2 home births, then this one.) Robin continued to pray and do CPR. The mother was still standing; Robin finally had someone get the mother a stool so she could sit down. She said to the mother, “Joy, talk to your baby.” She reached down and stroked the baby’s cheek and says “Natsuki, even if you have to die, I love you.” Robin’s husband took the baby’s little foot and blew on them and gently, saying “Come be with us.” Right after this, the baby girl let out the biggest scream. This girl is now so smart that she’s fast-tracking through her science classes. The grandmother came in an hour after the birth. She held her granddaughter and adjusted something in the baby’s jaw. All of a sudden this baby, who wouldn’t nurse, latched on right away. This was Robin's first breech birth.

About 4 years ago, a mom came in for prenatal care. She was carrying a breech baby. They tried ECV, but quickly abandoned it because the heart tones went really crazy. The parents were adamantly against a cesarean; the father had had many dreams that if his wife had a cesarean, she’d die. The baby was born footling breech. The baby came out easily, but died 9 hours later. He had only 2 vessels in his cord. The mother came back 18 months later for her next birth and wanted her baby born in the same room with the same midwives.

Almost all of the 6 million voters for the CNN Hero of the Year finalists voted for Robin Lim. She got lots of votes from Russia, Japan, Australia, and of course Indonesia. Her son-in-law is a big grunge rocker in Indonesia and would promote her contest and breastfeeding before his concerts.
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Evolution of Breech Birth: Heads Up! Breech Conference

Day 1: 
Betty-Anne Daviss:

The Evolution of Breech Birth: 

Why We Need the Wisdom of Our Ancestors & Other Cultures

She’s interested in breech birth from an anthropological perspective. Her presentation covered 3 main topics:
1. The history of breech birth: sorting through the myths and realities
2. The Noble Lie & human rights: why practitioners need to stop pretending and women need to become less gullible
3. Boundary crossing and elements that create change

Playing “make believe” allows children to deal with fears in a safe setting. Plato referred to a concept of “the Noble Lie”—that politicians need to lie to create myths that comfort and cohere a population. This is an adult form of "make believe." What is the greatest Noble Lie our culture tells about Childbirth? Women need to be saved most of the time.

Betty-Anne trained with traditional midwives in Guatemala several decades ago. She keeps going back to what they taught her, finding their insights to keep proving true. She also strongly reveres the black Granny Midwives, whom she worked with in the 1980s.

Next, Betty-Anne gave a brief overview of the history of obstetrics in its cultural and historical context. Some of the things she touched on:

• The work of Eric Bracht, known for the Bracht maneuver. She tried to mimic what would naturally happen in a gravity-positive position and created obstetrical maneuvers to simulate those movements with the mother on her back. 
• Reduction of maternal mortality fell drastically in the 1930s and 40s due to antibiotics, safe anesthetics, and blood transfusion. Starting in the 1950s, cesarean sections became increasingly safer. 
• Overview of cesarean rates in the last several decades. 
• Why is Bracht so important? He began making...but failed..to complete the link between gravity & breech birth. 
• Final interpretation of the Term Breech Trial (TBT) found that the risk is very minimized if: the baby is not IUGR, labor is spontaneous, good labor progress, shorter second stage, & experienced practitioner present.
• Recent discoveries on importance of vaginal birth in colonizing the baby with the mother’s gut bacteria 
• Referred to economist Daniel H. Pink’s book A Whole New Mind. 
• European observational studies of breech that we’ll be looking at during this conference: Scandinavia, PREMODA, 2006 French study. 
• Agnes Gereb and human rights issues in childbirth 

Betty-Anne just had a meeting this week with Montfort Hospital in Ottawa. They just waived the requirement to have an obstetrician present at all breech births. It’s now the first hospital in North America to allow midwives to attend breech births as the primary caregiver!

She lamented that ACOG is not present at this conference, despite intensive efforts from many organizers and physicians. In contrast, the SOGC has been involved in breech activism for several years now.

We need to carefully study women and contemplate what they need, what they know, and what they are capable of. “I don’t believe in compromise; I never have,”  she commented. She ended her presentation with this observation: We need collaboration, not compromise or co-optation.
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Opening Remarks of the Heads Up! Breech Conference

I'll be posting each session of the 3rd International Breech Conference separately. Please pardon any typos or awkward wording; I'm trying to get these session summaries up quickly!

Day 1: 

Opening Remarks by Robin Guy

Robin Guy, one of the founders of the Coalition for Breech Birth (CBB), welcomed us all and told the stories of her two children’s births. Her first was an easy homebirth. During her 2nd pregnancy, her daughter was breech and she looked desperately to find a care provider after trying everything to get her to turn. She even did ECV 4 times with 2 different care providers. This was before the 2009 SOGC guidelines reopening vaginal breech birth as an option. There were 2 “closeted” OBs in all of Ottawa that would catch a breech if she walked in late in labor and refused a cesarean. They were on call on different days and she had the misfortune of going into labor at the wrong time. The OB on call did not feel she could safely provide a vaginal breech, so she was forced to consent to a cesarean.

Our care providers need to know that women exist after their 6-week visit. 6+ years later, Robin still can’t get through her birth story. This long-term trauma is not unusual for women who experience violations of their autonomy. She still flashbacks, not to the surgery, but to the fighting beforehand. The problem wasn’t the surgery; the problem was the removal of her rights and of her bodily autonomy. She experienced this as assault. Legally, women aren’t protected from assault in a hospital, and there is no legal ground for recourse.

After this birth, Robin got angry and wrote lots of letters, sending them to every hospital in Ottawa. She and two other women got together in a park and came up with the idea of the CBB. They said nobody is fixing this; I guess it’s up to us! They communicated their concerns via a petition to the Society of Obstetricians & Gynaecologists of Canada (SOGC), which helped influence the 2009 protocols. Now, the CBB has 8 formal chapters in 5 countries and over 1,500 members. They have a two-pronged approach: exerting pressure from consumers and training providers.

In Ottawa, 3 of the 4 hospitals now support vaginal breech birth (VBB) attended by obstetricians. It still isn't offered; women have to tell their OB they want a VBB. What about the midwives? In Ontario, it’s within their scope of practice but is discouraged from taking place at home. However, the hospitals don’t tend to respect that scope of practice and mandate a transfer of care from the midwife to the hospital physicians. In other words, you can go in with someone like Betty-Anne Daviss, who has extensive experience in VBB, and you’re still obliged to transfer to someone of lesser skill. They’re still working on getting hospitals to allow experienced midwives to attend VBB.

There’s a private breech catcher group at LinkedIn that Robin moderates. It’s a safe space for breech-friendly birth professionals to talk to each other. Please join if you’re a midwife or physician interested in or currently catching breech babies.

Other ways to contact CBB:
robin@ breechbirth.ca
www.breechbirth.ca
Twitter: @breechconf
coalitionforbreechbirth@groups.facebook.com
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Heads up!

I'm headed to the 3rd International Breech Conference in a few hours. I'll be going without any little children in tow. As much as I love my kids, I am really excited to be on my own! I plan on taking copious notes and staying up (reasonably) late.

If you're coming to the breech conference, come say hi!

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Any Czech speakers out there? (updated)

I need help translating a few articles from Czech into English. They discuss recent Czech petitions to the European Court of Human Rights regarding home birth. I've run them through Google Translate and it gave me a very rough translation--enough to get the gist but not much else. Can anyone help?

Here are the articles:

• (Most important) http://www.tyden.cz/rubriky/domaci/budouci-matky-a-porodni-asistentky-zazaluji-cesko_222281.html
• http://www.tyden.cz/rubriky/domaci/zdravotnictvi/soudce-zadostem-o-asistentku-pro-domaci-porod-nelze-vyhovet_234030.html
• http://www.tyden.cz/rubriky/domaci/zdravotnictvi/zakazane-porodni-asistentky-radi-zenam-aspon-po-telefonu_246301.html 
• http://www.tyden.cz/rubriky/domaci/zdravotnictvi/zeny-budou-rodit-doma-bez-dozoru-desi-se-asistentky_229532.html
• http://www.tyden.cz/rubriky/domaci/zdravotnictvi/liga-lidskych-prav-chce-u-soudu-prosadit-narok-zen-na-porod-doma_234907.html

The best Google Translate parts:

For example any cesarean should be feasible within 15 minutes. And to do this is by midwives needed including incubator, the delivery room and anesthesia machine. In addition, perform the "Emperor" can only doctor. 

What if we started referring to a cesarean section as an "Emperor"?

We'd have the Unneccesemperor...Vaginal Births After Emperor...Elective Emperors...Court-Ordered Emperors. Quite the ring.

This one really made me laugh:

Farrowing houses as a possible compromise

Now we can stop having vaginal births after Emperors in birth centers and start having them in farrowing houses! 

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Birthdays, milestones, and more

Zari turned 6 on Halloween. She requested a "fairy garden cake." I don't know why you'd want to spend hours making fake flowers out of frosting when you can just use the real things. Voilà! Instant cake decorations.

Inga is 20 months old. Can you believe it? She's saying tons of words, putting two words together (baby doll, mama shoes, Dio car, two bears, etc.) and generally kills us with her uber-cuteness.

I made Zari a costume out of tons of scraps of fabric. Not really sure what she is, but a "gypsy" was the closest we could come up with. I have enough fabric left to make Inga a matching dress. Some day I'll get to it...

The other kids got recycled costumes. Dio was a butterfly (Zari wore this when she turned 4).

Inga was Little Red Riding Hood. (Zari wore this when she turned 1 and 2.)

Best news of all this week: my older sister had her first baby the day after Zari's birthday! Everything went as planned. With her husband and doula to help her, she had an unmedicated hospital birth and a fairly quick labor. Her water broke early in the morning. They went to the hospital a few hours later. Labor started almost as soon as they got there, and the baby was born after just 5 hours of active labor. The hospital is Baby-Friendly and has been really great. Woohoo! I love it when things go right.
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Safely increase vaginal breech rates with a written protocol

A 2011 study at a tertiary hospital in France found that implementing a written consensus protocol for breech increased the rates of vaginal breech birth without compromising safety. From 2000-2004, before the protocol was implemented, the vaginal breech birth rate was 24% (planned rate 30%). Once the protocol was adopted in 2004, vaginal breech rates began rising. The rate averaged 38.5% (planned rate 44.5%). The study included 1133 breech presentations at term over the 8-year period. After the study ended in 2008, the vaginal breech rate continued to rise, exceeding 50% in 2009.

Here are more specifics on the written protocol:

Before 2003, the authors’ department had no written protocol for breech delivery, except for the general French recommendations for radiographic assessment of maternal pelvimetry and ultrasonographic evaluation of fetal size. The authors’ team set up a working group to develop a protocol to decide the type of delivery for breech presentations as an institutional change of practice. The staff approved the final protocol by consensus in June 2004. It was based on practices followed locally by obstetricians, but not previously described or discussed in writing. The protocol indicated that external cephalic version should be proposed before 36 weeks of gestation, and X-ray pelvimetry should be offered around 36–37 weeks of gestation to women whose fetus remained in breech presentation. A fetal ultrasound was also planned to measure biparietal diameter, estimate fetal weight, and verify that the head was not hyperextended (a contraindication to attempted vaginal delivery in the protocol). This ultrasound was to take place in the delivery room unless a previous ultrasound had been taken within the last 7 days. The biparietal diameter was compared with the results of the pelvic measurements. Regardless of whether the breech presentation was frank or complete, vaginal delivery was considered appropriate when three conditions were met: (1) obstetric conjugate– biparietal diameter 15 mm; (2) median transverse diameter– biparietal diameter 25 mm; and (3) interspinous diameter– biparietal diameter 0 mm. In all other situations, vaginal delivery was considered inappropriate. A further condition for vaginal delivery was an estimated fetal weight 3800 g in nulliparous women (there was no cut-off for parous women). A woman arriving in labour without any previous pelvimetry could only have a vaginal delivery if the fetal weight, estimated by ultrasound, was <2500 g or if she had previously had a vaginal delivery of an infant weighing >3800 g. A previous caesarean section and uterine malformations were not contra-indications to vaginal delivery. All women had continuous electronic fetal monitoring during labour. All breech deliveries were performed with an anaesthetist and an obstetrician experienced in the necessary manoeuvres present in the delivery room. In all cases, this information was given to the woman and discussed with her when the measurements were compared.

The authors discussed their findings in relation to the Hannah Term Breech Trial and the more recent PREMODA study from centers in France and Belgium:

These results confirm the findings of recent studies [7–11] that vaginal delivery of breech presentations is not accompanied by increased neonatal morbidity and mortality, as reported by Hannah et al. [1]. The difference in results can be explained by the differences in levels of experience and selection criteria. For example, pelvimetry was only performed in 10% of cases in the study by Hannah et al.; this percentage reached 82.5% for the planned vaginal deliveries in the PREMODA study [7] and 95.3% in the present study. Moreover, 21.4% of the vaginal breech deliveries in the study by Hannah et al. were performed by obstetricians in training or inexperienced midwives. In the present study, an anaesthetist and an obstetrician with at least 5 years of experience were present in the delivery room. The PREMODA study found that specific manoeuvres were necessary in 34.4% of breech deliveries, including 13.4% for retention of the aftercoming head [7]. In the present study, 11.3% of deliveries required forceps and there were no cases of cervical head entrapment.

The most fascinating part of the article came at the end of the discussion section, where the authors hypothesize that increased patient and care provider confidence in the safety of vaginal breech birth explain the rise in vaginal breech birth rates. Emphasis mine:

This study found an increase in the percentage of successful vaginal delivery of breech presentations from 24% in 2000 to 38% in 2008. This increase cannot be related to more favourable pelvic-tobiparietal comparisons, as this rate was similar before (77%) and after (72%) implementation of the protocol. Given that there were no changes in practice for breech deliveries except for implementation of this protocol, it is hypothesized that the reduction in the caesarean rate from 76% in 2000–2004 to 61.5% in 2004–2008 was due to practitioners’ increasing confidence in the safety of vaginal delivery. Moreover, the confidence of both practitioners and women appears to be bolstered by the systematic checking of ‘objective margins of security’ related to fetal biparietal diameter before allowing vaginal delivery. Finally, the reduction in the caesarean rate for breech delivery was part of an overall decrease in the caesarean rate in the authors’ department during this period (from 22% in 2000 to 17% in 2008). It was not possible to determine which aspects of the protocol were essential to increase the number of vaginal deliveries without increasing neonatal complications. The rate of refusal of vaginal delivery by women decreased from 19.3% in 2005 to 4.8% in 2008 (data not shown). This indicates that acceptance of the protocol also reassured the women, probably mediated by the physicians’ increased confidence. The trend since 2004 was confirmed in 2009, when more than 50% of breech presentations at the hospital were delivered vaginally.

The French hospital's protocol is similar to the 2009 SOGC guidelines on vaginal breech birth. Here is a summary of the Canadian guidelines for vaginal breech birth:

• Baby is frank or complete with a flexed or neutral head attitude
• No cord presentation, pelvic abnormalities, fetal growth restriction, or macrosomia
• Baby's EFW is between 2500-4000g; EFW should be done within 10 days of onset of labor
• Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labor
• The HCP must be experienced in vaginal breech birth; an experienced OB should also be present to supervise other HCPs. HCP skilled in neonatal resuscitation should also be present at time of birth
• Passive 2nd stage of up to 90 minutes, followed by an active 2nd stage of 60 minutes

Interestingly, the SOGC does not recommend radiographic pelvimetry. The guidelines note: "Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the
best indicator of adequate fetal-pelvic proportions."

The SOGC also rigorously supporis a woman's right to informed consent & refusal: "Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care." 

Email me if you'd like a copy of the study! 

Citation:
S. Michel, A. Drain, E. Closset, P. Deruelle, A. Ego, D. Subtil. Evaluation of a decision protocol for type of delivery of infants in breech presentation at term. European Journal of Obstetrics &amp; Gynecology and Reproductive Biology. 158 (2011) 194–198.

Relevant references: 
[1] Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356:1375–83.
[7] Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11.
[8] Uotila J, Tuimala R, Kirkinen P. Good perinatal outcome in selective vaginal breech delivery at term. Acta Obstet Gynecol Scand 2005;84:578–83.
[9] Krupitz H, Arzt W, Ebner T, Sommergruber M, Steininger E, Tews G. Assisted vaginal delivery versus caesarean section in breech presentation. Acta Obstet Gynecol Scand 2005;84:588–92.
[10] Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004; 103:407–12.
[11] Vendittelli F, Pons JC, Lemery D, Mamelle N. The term breech presentation: neonatal results and obstetric practices in France. Eur J Obstet Gynecol Reprod Biol 2006;125:176–84.

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2 million

My stat counter hit 2 million today! Thanks to all of you for reading and keeping this blog alive. I've had the occasional existential blogging crisis, wondering if I was actually making any difference. But your stories and your emails have kept me going.

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Selective vaginal breech delivery at term--still an option

Breech is on my mind, as I'm preparing to speak at the 3rd International Breech Conference in 2 weeks. I just came across this cohort study from a hospital in Finland: Selective Vaginal Breech Delivery At Term--Still An Option.

Here's a flowchart of the comparison groups and their planned vs. actual modes of delivery. Email me if you'd like to read the full text!

Citation

TOIVONEN, E., PALOMÄKI, O., HUHTALA, H. and UOTILA, J. (2012), Selective vaginal breech delivery at term – still an option. Acta Obstetricia et Gynecologica Scandinavica, 91: 1177–1183.

Abstract

Objective. To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses.  

Design. A cohort study.  

Setting. Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries.  

Population. The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls.

Methods. The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined.  

Main outcome measures. Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points.  

Results. There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions.  

Conclusions. Vaginal delivery remains an acceptable option for breech delivery in selected cases.

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How to get to school in style

I still haven't made any headway on getting a crossing guard near Zari's elementary school. I've talked multiple times to the school transportation department, the state highway department, the police chief, and more. Since no one was willing to DO anything, I took matters into my own hands:

With the police chief's blessing, I should add. He said he couldn't technically give me crossing guard equipment for liability reasons, but...

"But," I asked him, "there's nothing stopping me from buying my own equipment?"

"Exactly!"

The crossing guard equipment makes a huge difference. Cars actually stop for us (they're legally required to at the crosswalk, but that doesn't mean anything in our town). I get a kick out of holding the stop sign and blasting my whistle at drivers who aren't paying attention.

I'd like a more permanent solution to access to this school building, but it does the job for us.

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Birth activism: let's get involved

There is lots of exciting birth activism going on right now. Please take a minute and join in one or more of these causes!

1. Human Rights Violations in the European Maternity Care  
http://www.change.org/petitions/human-rights-violations-in-european-maternity-care

If you're a member of the EU, sign this petition addressed to the European Parliament about human rights violations in maternity care. Sponsored by the Human Rights in Childbirth conference, the petition notes:

In 2010, the European Court of Human Rights in Strasbourg stated, in the case of Ternovszky versus Hungary, that “the right to respect for private life includes the right to choose the circumstances of birth”. However, many European States have systems of birth care in which women's physical autonomy is routinely violated and their options are rigidly circumscribed.

2.  Your Voice Counts Day 
http://www.facebook.com/events/415706168477663

Join women around the world in notifying hospital administrators and care providers about their experiences of giving birth. This movement asks women and their families to mail letters on or around Thanksgiving Day (Thursday, November 22). More about Your Voice Counts Day here. If we want to make changes in maternity care, we need to let care providers and institutions know how we feel about the care we've received!

Did you have a wonderful, empowering birth experience? Did you have a traumatic birth experience that made you feel hurt and confused? Stand up and tell somebody! On Thursday, November 22nd (Thanksgiving) join us in mailing letters to hospital administrators, birth center directors, and other birth workers to tell our stories. How will hospitals and birth workers know how they're doing if we don't tell them? Whether your birth happened sixty minutes ago, sixty days ago, or sixty years ago, your experience matters. We cannot be ignored if we unite and flood these establishments with letters at the same time. Stand up and be counted on Your Voice Counts Day. 

3.  Freedom For Birth 
http://www.freedomforbirth.com/

The documentary Freedom For Birth examines childbirth as a human rights issue. It had a global premiere on September 20th. I was tied up that day and unable to attend a screening, but the movement to spread awareness is just beginning. I ordered the DVD last week and can't wait to watch it.

4. Birth Action in Canada
http://yourbirthcoach.com/birthaction

If you live in Canada and have experienced any violation of informed consent or human rights during your birth, please get involved by taking this survey. Organizer Dr. Nancy Salgueiro explains what she hopes to accomplish with these surveys:

Canadian courts have repeatedly reaffirmed a patient’s right to informed consent as well as the right to refuse treatment. IN ONTARIO, the Health Care Consent Act of 1996, clearly outlines your legal right to informed consent....

We have a arranged a group of Ottawa lawyers willing to volunteer to commission legal affidavits of the violations in your birth experience.   Once we compile enough legal affidavits these will be brought forward to force a public inquiry of the systemic abuses to women in childbirth.

She has also provided examples of violations of informed consent:

• Treatment occurred without YOUR PERMISSION.
• Treatment occurred after REFUSAL of consent.  (You said, No”)
• Treatment occurred without fully INFORMED consent.
• You were not informed or misinformed as to the NATURE OF THE TREATMENT.
• You were not informed or misinformed as to the expected BENEFITS of the treatment.
• You were not informed or misinformed as to the material RISKS of the treatment.
• You were not informed or misinformed as to the material SIDE EFFECTS of the treatment.
• You were not informed or misinformed as to ALTERNATIVE COURSES OF ACTION.
• You were not informed or misinformed as to the likely consequences of NOT HAVING THE TREATMENT.
• Consent was given but obtained through MISREPRESENTATION, OMISSION, COERCION or FRAUD.
• Consent was given but NOT GIVEN VOLUNTARILY. (Told you have no choice but to consent).
• Consent was given but DID NOT RELATE TO THE TREATMENT that was provided.
• You were DENIED RESPONSES TO YOUR REQUESTS for additional information about those matters.
• You were denied the opportunity to have a DISCUSSION with the DOCTOR/MIDWIFE about the proposed treatment.
• Consent only consisted of a form to sign when you walked in the door with NO DISCUSSION OR EXPLANATION BY THE DOCTOR/MIDWIFE.

I'm also interested in other recent activism, including the National Rally for Change on September 3 (Labor Day).

Did anyone participate in this or other recent birth activism? Please tell us all about it! 

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Vaginal breech, ECV, and NRP Workshops

I have another announcement to make...Not quite as exciting as my pregnancy, but pretty close!

We are organizing another workshop with Dr. J. Peter O'Neill, the Canadian OB who taught vaginal breech skills last summer in Indianapolis. This time, he will be leading two full-day workshops: Vaginal Breech Birth and External Cephalic Version with Ultrasound Guidance. Both sessions include hands-on simulation.

On top of that, we have a NRP course tailored for out-of-hospital attendants, taught by Penny Lane, CNM, MSN, IBCLC. This course will cover full resuscitation skills, including intubation, medication administration, and umbilical line placement.

The workshops will take place in Niceville, Florida on June 7-10, 2013. We also have some fun free sessions for conference participants, including evening conversation circles and film screenings.

You can mix & match any of the 3 workshop days. We are offering deep discounts for students and for early registration; sign up now to take advantage of these fantastic prices.

Please spread the word about the Vaginal Breech, ECV, and NRP workshops! More information can be found at www.breechworkshop.com.

Ps--any of you coming to the Third International Breech Conference in D.C.? I'll be there!

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First prental visit

It's nice to finally be able to blog about being pregnant! I've known for a while, but I just didn't feel like sharing with the whole world. Now it's beginning to be obvious that I'm pregnant if I wear a tight enough shirt, so no more secrecy.

This pregnancy is funny--I really don't know when to expect this baby! I'm either 16 weeks along or 12 weeks along. After my very early miscarriage, I thought I had another cycle...but it was really light and really short. Nothing like I've ever had before. I strongly suspect it wasn't a cycle at all, but just some breakthrough spotting that happened to come right when I would have had a period. Other reasons for thinking I'm 16 weeks along:

• I'm measuring spot-on for being 16 weeks pregnant: 2-3 finger widths below the umbilicus. 
• I started feeling movement about 4 weeks ago. 
• The timing of my icky/queasy/exhausted stage also points to being 16 weeks, not 12 weeks. 

But...I can only say I'm about 95% sure. There is still the possibility of my baby coming in late April rather than late March! This uncertainty doesn't bother me at all. In fact, I like not really knowing and not really caring.

The icky stage was pretty awful. And I know I have it easy compared to so many other women. I never puke; I just feel queasy all day and all night. I feel dizzy and weak. I am extremely exhausted. Like my other pregnancies, these symptoms lasted about 6 weeks. But this time was brutal. I've never experienced such exhaustion before. And when you have three small children, you can't just lie on the couch all day! I'd basically collapse once Eric came home.

My best coping strategy was reading; I devoured my way through books 2-5 of Diana Gabaldon's Outlander series. I highly recommend her books: they're smart, entertaining, passionate, and incredibly well-researched.

But now I feel great. I have tons of energy, I have an appetite again, and I am not a useless blob who neglects her children in favor of reading a book. Take today, for example: I taught my 8 am freshman composition class (biking there and back), sewed 4 slings, fed the children lunch, worked on a vaginal breech workshop I'm organizing, walked the kids to pick up Zari from school, went to my first prenatal appointment, prepared 2 dinners for later this week while Eric cooked fried green tomatoes, and put Inga and Zari to bed. I couldn't fathom doing any of these things earlier this pregnancy--except I had to do some of them.

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Freeze family math

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Optimal Care in Childbirth

I'm really excited to review Henci Goer and Amy Romano's new book Optimal Care in Childbirth: The Case For a Physiological Approach. In fact, I've put off writing about some other exciting developments in order to finish this review.

I've read through the whole book once and skimmed through many chapters a second time. That's no small feat, considering the book is a hefty 583 pages with small font.

Optimal Care in Childbirth is an outgrowth of Goer's two earlier books that made sense of maternity care research and obstetric practices: Obstetric Myths Versus Research Realities: A Guide to the Medical Literature (1995) and The Thinking Woman's Guide to a Better Birth (1999). Henci Goer has been a medical writer, speaker, and consumer educator for the past few decades. Amy Romano is a nurse-midwife with clinical experience in both home and hospital settings. She currently works as a consumer advocate with Childbirth Connection.


So what is Optimal Care in Childbirth about? What does it accomplish? And is it worth the investment? My answer is an unqualified yes. Here's why:


Optimal Care in Childbirth is not simply an updated version of Goer's earlier books. It delves deeper into factors driving maternity care, analyzes an expanded body of research studies, and critiques even more forcefully the abundance of poorly designed research and the gap between research and practice  In Goer and Romano's own words, the book examines:

• why the research shows so little benefit for physiologic care and so little harm from medical-model management
• what’s behind the cesarean epidemic
• what the research establishes as optimal care for initiating labor, facilitating labor progress, guarding maternal and fetal safety, birthing the baby, and promoting safety for mother and baby after the birth
• the true, quantified risks of primary cesarean surgery, planned VBAC versus elective repeat cesarean, instrumental vaginal delivery, and regional analgesia
• how the organization of the maternity care system adversely impacts care outcomes

The book begins with three introductory chapters. The first explains the impetus for writing the book. Goer and Romano note that while careful use of technology and obstetric intervention can save mothers and babies, injudicious obstetric practices do "considerable physical and psychological harm to mothers and babies." Their book sets out what optimal maternity care--"the least use of medical intervention that will produce the best outcomes given the individual woman's case"--can and should look like.

The second chapter examines the weaknesses of medical research. Although the rise of evidence-based medicine (EBM) is an improvement over the older GOBSAT (Good Old Boys Sat At Table) model of obstetric decision-making,  EBM has several downfalls. The privileging of randomized controlled trials (RCTs) often means that other kinds of studies are dismissed, even though they contribute important information. RCTs themselves are subject to poor design and flawed interpretation, and systematic reviews are no less immune to bias. Finally, EBM has become an almost inescapable dogma that precludes other ways of knowing and discourages individualization of care. Despite these drawbacks, EBM still holds promise for pointing to maternity care strategies that work to promote minimal harm with maximum benefit. Goer and Romano comb through the research literature, summarizing and clarifying what we do and do know know, explaining what works and what does not.

The third chapter gives readers an orientation to the rest of the book. They present their methods upfront, arguing that transparency is the best antidote to bias.

The rest of Optimal Care in Childbirth tackles the evidence and customs behind the following maternity care practices:

• cesarean sections (including cesarean rates, repeat cesareans, and VBAC)
• facilitating labor progress (induction, progress of labor)
• guarding maternal and fetal safety (fetal monitoring, oral intake in labor, epidurals)
• birthing the baby (second stage practices, instrumental vaginal delivery, fundal pressure, episiotomy)
• promoting safety for mother and baby after the birth (third-stage management, newborn practices)
• optimal practices for a maternity care system (supportive care in labor, midwife-led care, birth centers, and home birth)

Each chapter begins with an analytical essay explaining the historical and cultural influences behind the obstetric practice in question. The essays then summarize the evidence and examine how far evidence strays from practice. These essays are lively, impassioned, and wonderfully humane in tone. One would expect a book summarizing and interpreting medical evidence to be dry reading, but these essays are refreshingly enjoyable. Biting wit and humor intermix with thoughtful analysis and provocative questions.

Following the essays, Goer and Romano provide a concise list of strategies for optimal care based on the evidence. Here's an example of optimal care strategies from the chapter on second stage (pushing) practices:

The following strategies facilitate a physiologic second stage, maximize the chance of spontaneous birth, and minimize the chance of genital, perineal, or pelvic floor injury:

• Encourage non-supine positions. 
• Avoid interventions that restrict movement and position-changes. 
• Make physical props available and encourage position-changes, enlisting labor companions to assist with support, encouragement, and mobility as needed. 
• Encourage women to follow their spontaneous pushing urges. Discourage prolonged breath-holding. 
• If coaching seems prudent, suggest open-glottis techniques rather than prolonged breath-holding. 
• In women laboring with epidural analgesia, await a spontaneous bearing down urge before beginning active pushing efforts. Encourage open-glottis pushing when the urge develops. 
• Use a supportive and encouraging communication style to promote the woman's sense of safety and wellbeing and diminish her fears. 
• Guide the laboring woman in birthing the baby's head gently between contractions.

Finally, each chapter ends with several mini-reviews of the available research. The reviews carefully note inclusion/exclusion criteria, study design and limitations. and clarifying information. The mini-reviews are where you can really dig deeply into the research evidence. Mini reviews are numbered and organized by topic.

I was struck by how difficult it is to design studies that capture the nuances of an intricate physiological process. Despite mountains of research, very few studies measure more than one small element at a time. That is the nature of medical research, but it works poorly for understanding the complex, interconnected nature of human labor and birth. Too often, a study's design guarantees that very little difference will be found between the "control" (usually an intervention) and the "intervention" (sometimes another intervention, other times a physiologic practice such as oral hydration or walking during labor). Isolating one small practice while keeping the overall package of care unchanged usually shows minimal results.

I was amazed at how much information Goer and Romano were able to glean, despite the limitations of obstetric research. Overwhelmingly, the evidence points to the value of doing less--or rather, the value of understanding and supporting the physiological process so that labor and birth can unfold without undue complication or interference. It's not that obstetric technology has no place; it's just that most of the time, that technology could be safely replaced with patience, respect, careful observation, and following the woman's lead. In order to shift to this style of maternity care, we need studies that examine not just one small change at a time, but that compare entire packages or systems of care. Ambulation during labor in a conservative hospital environment might make little difference in the course of a woman's labor. Ambulation in a care setting that encourages mobility, provides a full range of non-pharmaceutical pain relief options, upholds maternal preference and autonomy whenever possible, and discourages routine use of technology is another story.

Optimal Care in Childbirth is a book we cannot do without. Imagine if every maternity care facility--from the busiest tertiary hospital to the smallest home birth practice--adopted all of the strategies for optimal care set out in Goer's and Romano's book. We would have a maternity care system that supports the wants and needs of laboring women, no matter their location or their individual health profile. We would have a system that delivers optimal care--promoting the physiological processes whenever possible and providing obstetric interventions judiciously and appropriately. We would have a system that uses fewer resources, leads to fewer physical and psychological complications, and has healthier, more confident, more satisfied mothers.

~~~~~

Optimal Care in Childbirth is available at www.optimalcareinchildbirth.com and retails for $50. The authors have offered Stand and Deliver readers a special 15% discount and free domestic shipping through October 31st. Use coupon code MOQLM3W8. Also available on Amazon.

Disclosure note: Goer and Romano provided me with a review copy and invited me to participate in a referral program.

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