Gail Tully: Visualizing (Obstructed) Breech Birth

First Amsterdam Breech Conference, Day 1

Gail Tully

Visualizing (Obstructed) Breech Birth:

Breech Complications Illustrated, 

Particularly Trouble with Rotation or Flexion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Illustration by Frank Louwen

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

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

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

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

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

When baby’s head is stuck: 
First you must know what normal looks like for the birth of the head. For an upright breech birth, you will notice:

• Head flexion
• Perhaps a bit of chin or face emerging from the perineum
• Full perineum
• Mother's anus is open

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

Rixa's note: I have seen two variations of the shoulder press, a.k.a. "Frank's nudge," demonstrated at this conference. Anke Reitter prefers holding the baby by its shoulders, the thumb in front and the fingers wrapped around the back of the shoulders.

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

In an email correspondence after the conference, Gail clarified:

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

With either variation, press straight back towards the mother's pubic bone. Don't press down!

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

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

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

Breech and birth pools
It can be hard to make adaptations in the birth pool. Or if the mother is crouched way too far down, almost sitting on top of her heels with her torso to the floor, it can close her pelvis a bit. When women are on all-fours in the birthing pool, their thighs are flexed in varying degrees, all of which slightly or notably close the inlet (see articles by Desbriere, Guittier, and Reitter). Gail is not favorable for water births for breeches, generally. She believes that being in the water closes the AP inlet. Gravity can help bring the baby down more quickly when the mother is on land. In a post-conference email correspondence, Gail added:

When babies come quickly, water birth can be best, but when a breech is stuck, it is not desirable to have mother move so significantly as to get out of the pool with the baby's body out and head remaining inside. To open the pelvis optimally for a breech baby's head, the thighs need to move away from the abdomen, which would put a woman's head under the water!

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

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

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Three Perspectives on External Cephalic Version

First Amsterdam Breech Conference, Day 1

Three Perspectives on External Cephalic Version (ECV)

Marjolein Kok

Turn That Breech!: Important Aspects Of ECV

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

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

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

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

Eligibility: There is very little consensus on contraindications for ECV. In the five national guidelines surveyed in the above meta-analysis, there were 18 total contraindications, but only one was shared between all five guidelines: oligohydramnios. In addition, no contraindications in the literature were evidence-based, thus leaving only level III evidence (expert opinion) to guide decision-making. Her own level III recommendations for contraindications are:

• History of placental abruption
• Signs of placental abruption in current pregnancy
• Severe preeclampsia or HELLP syndrome
• Signs of fetal distress

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

How? When Marjolein Kok performs ECV, she follows the following procedures:

• CTG to determine fetal-wellbeing
• Ultrasound to determine presentation
• Examination
• Ultrasound gel (she feels it helps the operator's hands glide smoothly)
• 2 operators (I didn't write down her reason for having two people present)
• Tocolysis
• Head roll
• Anti-D immunoglobulin for Rh- women

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

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

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

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

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

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

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

Joost Velzel

How To Improve the Effectiveness Of ECV

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

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

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

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

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

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

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

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

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

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

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

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

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

• Reinhard J, Heinrich TM, Reitter A, Herrmann E, Smart W, Louwen F. (Oct 2012) Clinical hypnosis before external cephalic version. Am J Clin Hypn. 55(2):184-92.
• Reinhard et al (2012). The Effects of Clinical Hypnosis versus Neurolinguistic Programming (NLP) before External Cephalic Version (ECV): A Prospective Off-Centre Randomised, Double-Blind, Controlled Trial. Evidence-Based Complementary and Alternative Medicine Volume 2012. 

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

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Betty-Anne Daviss: Cardinal Movements and Crowning Touch

First Amsterdam Breech Conference, Day 1

Betty-Anne Daviss, RM, MA

The Usually Reliable Cardinal Movements of the Vaginal Breech

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

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

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

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

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

Tips & tricks

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

Question & Answer Session

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

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

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

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

First Amsterdam Breech Conference, Day 1

Dr. Frank Louwen

The Re-Invention of Vaginal Breech Birth

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

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

Now on to Dr. Louwen's presentation:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Never pull, only push the baby.”

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

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

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

Q&A session

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

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

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

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

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

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

Sources cited:

• Martin et al. (2005). Preliminary Births for 2004: Infant and Maternal Health. CDC National Center for Health Statistics.
• Thavagnanam, S., Fleming, J., Bromley, A., Shields, M. D. and Cardwell, C. R. (2008), A meta-analysis of the association between Caesarean section and childhood asthma. Clinical & Experimental Allergy, 38: 629–633.
• Cardwell et al. (2008). Caesarean section is associated with an increased risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of observational studies. Diabetologia. 2008 May;51(5):726-35.
• Almgren, Malin et al. (Nov 2014). Cesarean delivery and hematopoietic stem cell epigenetics in the newborn infant: implications for future health? American Journal of Obstetrics & Gynecology , Volume 211 , Issue 5 , 502.e1 - 502.e8

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First Amsterdam Breech Conference: Welcome Speeches

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

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

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

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

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

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

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

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Chamonix and Mont Blanc

We took a 3-day trip to Chamonix, a village high in the French alps at the foot of Mont Blanc. Eric was invited to give a reading at the Mont Blanc Writing Workshop, reading from Hemingway on a Bike. Why not make a family trip out of it?

The drive took us 4 1/2 hours, along the Italian coast, up through the central plains growing arborio rice, and back into France at the very end. We went under 154 tunnels on the way there, including the longest tunnel I've ever driven in--the tunnel going right underneath Mont Blanc!

This trip was epic in more than one sense. We did both drives without stopping. You might not be all that impressed, if you've never gone on a road trip with four small children.

The best part, though, was the hiking. Day 1 was cloudy, misty, and rainy. Good for short hikes. Day 2 was a rare day of sunshine in an otherwise unusually rainy June. We opted to hike to Montenvers Mer de Glace (Montenvers Glacier).

Last year Eric ran up to the top in 45 minutes, so we were under-prepared for how long and difficult it would be (1 mile vertical gain according to my GPS map and 11.4 miles long according to my fitness tracker). I didn't bring enough water and we ate every last crumb of our food at the top. I also had to cajole a very cranky Zari into not giving up. She was ready to head home after less than 2 hours of hiking.

But we made it! And everyone--Zari included--loved reaching the summit, watching an avalanche, riding a gondola down to the glacier, and walking through ice caves.

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This weekend's hike: Vallon obscur du Donaréo

Scroll down for directions on how to find the trailhead.

Our across-the-street neighbors recommended hiking the vallon obscur du Donaréo, a hidden valley just outside of Nice. I'm writing up about our hike because we had the hardest time finding the trail head! It's not even a proper trail, except there is one sign at the beginning. Unless you know where to go, you'd never find it.

As we began the hike, the canyon walls lengthened and narrowed, cutting off the sunlight and casting us into a cool gloom. We had entered a magical world. We hopped over a small stream running through the bottom, occasionally dipping our feet in the cool water. The canyon walls were covered with moss, ferns, and sub-tropical vegetation. Mist and water droplets falling from above kept us cool--not that we needed to cool off any more!

Also lots of frogs, tadpoles, and lizards.

Back to reality--how do you get there? I visited many French sites describing the hike (here, here, and here, for example, but they weren't helpful enough to get us to the right place. We finally found it thanks to flagging down an old Niçois hiker.

Directions to the vallon obscur du Donaréo:
The valley can be hiked from the top (from Castagniers) or from the bottom, which is where we started.

1. Drive to the crematorium of Nice (Chemin du Roguez, 06670 Colomars). Take the road towards the crematorium, not to the Nécropole. Drive past the crematorium gates. 20 meters after the gates, park alongside the road or pull into a little gravel parking area on your right.

2. On your left, you'll see a chained-off road. Walk over the chain towards the concrete structures at the end.

3. Once you get to the end, slip through the little area on the right.

4. Walk along the wood planks, following the canal. Soon you'll cross over the canal and see a sign with information about the hike.

5. Go onto the little stream bed and start hiking up the valley. You can go as far as you wish. Near the top you will see an aqueduct; we didn't go this far as our kids were getting tired. The hike isn't strenuous, but there is some climbing over boulders and scrambling up and down steep slopes. Be sure to wear shoes that can get wet!

A short preview...



A longer look...

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New version of "Breastfeeding With Comfort and Joy"

A recent doula client and friend stopped by before I left for France to borrow some birth and breastfeeding books for the summer. She picked up Laura Keegan's Breastfeeding With Comfort and Joy and said, "I love this book! It was the most helpful breastfeeding book I read before I had my baby."

I reviewed Breastfeeding With Comfort and Joy back in 2009. I am excited to announced that Laura has released an revised e-book edition with updated information (particularly regarding skin-to-skin care and laid-back breastfeeding), more photos, and nine videos. Some e-book formats play the videos directly (Kindle Fire, Apple Books), while other e-book platforms will include a password-secured link to the videos.

The videos show babies of various ages taking the breast and feeding, some in upright positions and others laid-back. You'll also see 1-week-old twins taking the breast, a mother hand-expressing milk, and a mother doing breast compression to help her sleepy baby finish nursing. Another mom talks about nursing her baby right after the birth by putting her baby skin-to-skin and letting him scoot up to her breasts and latch on by himself. Finally, you'll see a UNICEF breast crawl video and watch a short documentary of a premature baby whose life was saved by skin-to-skin care after the birth.

Of particular importance are the new photos showing laid-back breastfeeding, with moms comfortably reclined and babies laying belly-down on top of their mothers. Laid-back breastfeeding enables babies' hardwired instincts to breastfeed, helps babies latch more deeply and effectively, and lets mothers nurse without having to actively "hold" their babies--a huge plus when you are nursing round-the-clock!

Laura wrote to me about this new version of Breastfeeding With Comfort and Joy:

When women see breastfeeding work, are confident to get comfortable, and fall in love with breastfeeding without the distractions and information overload, breastfeeding will become part of our culture.

I really want the new release pushed because it is an excellent resource for women to advocate for skin-to-skin at birth and other things. The information is not an update but a richer resource because of the shared experiences and practices that have come out since the first edition both in my practice and online. I now have more images to support the timeless concepts.

For the practice of women to have their babies at birth to reach a tipping point, women need an all-in-one-place resource when they demand this from their birth practitioners. Otherwise the scattered internet searches overwhelm them and the message is lost.

Please consider this book for yourself, for an expecting friend or family member, or for your medical/midwifery/lactation consulting practice.

The new electronic edition of Breastfeeding With Comfort and Joy is available from Amazon, Kobo, and iBookstore.

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Off to France again

We're spending the summer in Nice. We left last weekend with only 6 suitcases this time.

We pulled the kids out of school back home and put them in the French public school. All four children are in school this year, with Ivy in the "toute petite section" that starts at age 2.5. She did amazingly her first day, but the second day she clung to us and sobbed. She goes only in the morning. I love having school right around the corner and 2-hour lunch breaks!

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Update on homebirth VBAC ban in Colorado

The Colorado legislature recently included a VBAC ban into pending midwifery regulations. Thanks to consumer activism, the Senate has now rescinded the VBAC ban. Here's an update from Emily Thompson:

APR 22, 2016 — Yesterday, by unanimous vote, the Senate Health Committee removed the VBAC ban amendment from HB 1360 which will continue to keep midwifery legal in Colorado. Many midwives, mothers, advocates and their supporters testified in support of both the safety and the right of mothers to choose VBAC at home.

The signatures on this petition and the many comments definitely swayed the opinions of the Senators, and the strong testimony yesterday sealed the deal.

The bill still must be heard in the full Senate, and there is the possibility of amendments being added. We're asking Colorado residents to contact their State Senator and ask them to vote YES on HB1360 as it is presented to them from the committee.

Thank you again to everyone who signed, shared, and supported this grass-roots movement!

Gratefully,
Emily

If you're wondering why preserving women's ability to have a VBAC at home is an important issue, consider this: around 50% of all US hospitals ban VBACs, either formally (hospital policy) or informally (no doctors at that hospital will attend VBACs). In those situations, a woman's only remaining choice for VBAC is an out-of-hospital birth. Banning CO midwives from attending VBACs forces those women into having unnecessary, unwanted surgeries or from having to give birth unassisted.

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Human rights in childbirth: VBAC bans

A few human rights in childbirth cases in the news:

Low-income women in Oregon forced to have cesareans: 

If you are have a previous c-section, you might end up in Laura Blevins' shoes: no hospital providers in her area attended VBACs, yet Oregon Health Plan would not cover out-of-hospital VBACs. Laura had to pay out-of-pocket for birth center care in order to avoid an unnecessary cesarean and is now filing an appeal with the Oregon Health Plan. Read her full story on her blog or listen to this NPR piece. She started a GoFundMe campaign to raise funds for her legal expenses.

Laura Blevins

Colorado Legislation would ban VBAC at home:

This last-minute legislation would ban home birth midwives from attending VBACs. With around 50% of US hospitals already banning VBACs, this is a pressing human rights issue. Please sign the petition and, if you live in CO, contact your legislators!

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Two must-read pieces on physiology and "pronurturance"

Understanding and promoting physiology in childbirth has been an interest of mine since my graduate school years. See, for example, my one of my comprehensive exams that asked me to reflect on the intersection of childbirth and environmentalism, in which I explored biodynamic approaches to both our natural and our maternal environments.

I want to share two fascinating pieces that make a case for respecting and facilitating the hormonal physiology of childbirth, with the end goal of healthier mother-baby pairs:

The first is the article "Hormonal Physiology of Childbearing, an Essential Framework for Maternal–Newborn Nursing" by Carol Sakala, Amy M. Romano, and Sarah J. Buckley (JOGNN 45.2 264-275). From the abstract:

Knowledge of the hormonal physiology of childbearing is foundational for all who care for childbearing women and newborns. When promoted, supported, and protected, innate, hormonally driven processes optimize labor and birth, maternal and newborn transitions, breastfeeding, and mother–infant attachment. Many common perinatal interventions can interfere with or limit hormonal processes and have other unintended effects. Such interventions should only be used when clearly indicated. High-quality care incorporates salutogenic nursing practices that support physiologic processes and maternal–newborn health.

The second is a PhD thesis by Florence Anne Saxton of Southern Cross University: Pronurturance at birth and risk of postpartum haemorrhage: biology, theory and new evidence. (PDF here) From the abstract:

Background: In spite of the almost universal adoption of the active management of the 3rd stage of labour, postpartum haemorrhage (PPH) rates continue to rise; reaching 19% or more in some obstetric units. Conversely, there is emerging evidence that women who experience continuity of midwifery care have lower rates of PPH. Continuity of midwifery care normally includes immediate skin-to-skin contact and early breastfeeding in the 3rd and 4th stages of labour to optimise release of endogenous oxytocin. The objective was to determine if skin-to-skin contact and breastfeeding at birth affected the rate of early PPH in a group of mixed risk Australian women.
Method: De-identified birth records (N=11,219) for the calendar years 2009 and 2010 were extracted from the electronic ObstetriX database which records public sector births in New South Wales, Australia. Excluded (n = 3,671) were all cases where skin-to-skin and breastfeeding immediately after birth was not possible leaving 7,548 cases for analysis. The outcome measure was PPH of 500 ml or more; the independent variables were ‘skin-to-skin contact’ and ‘breastfeeding’ at birth (the combination of these two variables I ultimately termed pronurturance). Analyses were conducted to determine the risk of PPH for women who experienced skin-to-skin contact and breastfeeding at birth in the 3rd and 4th stages of labour compared with those women who did not (regardless of the woman’s risk status or mode of birth).
Results: Women who experienced skin-to-skin contact and breastfeeding at birth had an almost fourfold decrease in risk of PPH, (OR 0.26, 95% CI 0.20-0.33, p < 0.001). After adjustment for covariates women who experienced skin-to-skin contact and breastfeeding at birth were again less likely to have a PPH (OR 0.55, 95% CI 0.41-0.72, p < 0.001). This protective effect of ‘pronurturance’ on PPH held true in sub-analyses for both women at ‘lower’ risk (OR 0.22, 95% CI 0.17-0.30, p < 0.001) and ‘higher’ risk (OR 0.37, 95% CI 0.24-0.57, p < 0.001) of PPH.
Conclusion: These results suggest that skin-to-skin contact and breastfeeding in 3rd and 4th stages of labour was effective in reducing the risk of PPH in a group of mixed risk Australian women. The explanation of this finding is that skin-to-skin contact and breastfeeding promote optimal endogenous oxytocin release. Skin-to-skin contact and breastfeeding at birth has shown no known negative effects and should be encouraged for all women during 3rd and 4th stage labour care.

Here are some core elements of a physiological labor & birth

Mother moves freely & chooses her positions during labor

Quiet, private environment

Unobtrusive birth attendants

Spontaneous, mother-directed pushing and upright maternal positioning

Immediate & prolonged skin-to-skin contact

Still skin-to-skin, even when moving from tub to bed

Skin-to-skin and breastfeeding ad infinitum

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Happy birthday Inga and Ivy!

Happy birthday Inga (5) and Ivy (3)!

I don't have any pictures of Inga on her birthday, just videos, but here's her cake. She drew me a pictures of a multi-layered turquoise cake and said "make this cake for me, mama!" The inside was 3 shades of turquoise. 

Ivy just turned 3 yesterday. 

We didn't have wrapping paper, so we used play scarves from the toy shelves.

Ivy has been asking all week for "a crown, a rainbow skirt, some sparkles, and some jewels." I bought her a sparkly rhinestone headband and made her a rainbow skirt, so that takes care of all four, right?

Eric modeling the skirt on his head, to the great hilarity of all the children

She wanted a "rainbow heart cake" so here's what we did:

It's rainbow colored inside!

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Two must-reads and some (slightly) relevant puppy cuteness

Okay, serious things first: two must-read pieces.

The first is a fantastic writeup about the hormonal physiology of childbearing, written by Carol Sakala, Amy Romano, and Dr. Sarah J. Buckley. It's written for L&D nurses and gives specific suggestions for how to "promote, support, and protect" hormonal physiology in order to "optimize labor and birth, maternal and newborn transitions, breastfeeding, and mother–infant attachment." There are 1.9 CNE units offered via AWHONN, free for the next 50 days.

The next is a series of photos of an upright vaginal breech home birth, with fantastic explanations by the birth photographer. This is one of the best photo series of a VBB that I have come across: you can see the baby working himself out, step by step!

And last...some fluff. Watch a mama dog be reunited with her puppies. I love how they start crowding around to nurse within just a few moments. I had a moment of this myself today, when Eric and I came home after being away for 8 days at a conference. It was the first time we'd ever left all the kids.

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