Lawrence Impey: Literature on the management of term breech and the RCOG 2017 guidelines

Lawrence Impey

Literature on the management of term breech pregnancy 

including the RCOG 2017 guideline update

North of England Breech Conference, Sheffield

Day 1

Lawrence Impey, FRCOG, is a Consultant in Obstetrics & Fetal Medicine at John Radcliffe Hospital, Oxford. He is the head of the guideline group responsible for the new RCOG Breech guideline, published on March 16th 2017. He is widely published in the areas of labor, breech presentation and the origins of childhood handicap. He has written, edited and contributed to several leading text books in obstetrics and gynecology.

Dr. Impey is Director of the sub-specialty training program in fetal and maternal medicine in Oxford. He also lectures regularly locally at Oxford University, nationally and internationally. Within the NHS, Mr Impey specializes in complex pregnancy, particularly for women with multiple pregnancies and those at risk of preterm delivery. He runs the breech and external cephalic version (ECV) service.

Lawrence Impey opened by nothing how he enjoyed the conference that took place in Sheffield two years ago. Today he talked about the recently updated 2017 RCOG Green-top Guideline for Mangement of Breech Presentation (PDF here) and about the evidence on breech birth. It’s very odd that we dispute evidence or facts when facts are really facts. [This elicited ironic laughter from the audience--who knows better than midwives and obstetricians how disputed facts can be?]

When he and his team put together the new guideline, it was very obvious what the evidence showed. He’s slightly puzzled about why there’s been any dispute about it at all. What is important is that we give the facts in a proper, fair, and unbiased way. He hopes that his "dry" talk today will do this. What women do with this information is what matters. As OBs, we forget the difference between relative versus absolute risk, and we focus too much on the immediate risks versus the later risks.

The 2017 RCOG guideline created more of a stir than he had anticipated. He shared several rather scathing critiques of the new guidelines [from people who obviously were not very comfortable with vaginal breech birth]. Here are some of the criticisms:

• "In my opinion a biased look at the literature"
• "This recommendation is based on poorly designed studies and is designed to scare women into wanting a vaginal breech delivery"
• "We know many (if not most) of these women will require some kind of operative intervention in order to deliver (CS, forceps, generous episiotomy, fetal manipulation or even cervical incisions)"
• "...and we believe that the recommendation...is detrimental to maternal safety"

Another person found fault for different reasons:

• "this section does not respect the right of the woman to make informed decisions about place of birth"

Lawrence presented several key questions in the debate over breech birth: Is cesarean “safer” for a baby? And safer in what way? Is planned VBB safer for a cephalic baby than for a breech one?

In debates over safety, many different outcomes matter. Some are short-term, others long-term. Lawrence's presentation covered six main outcomes, all of which need to be taken into account.

• This baby: death (stillbirth, infant mortality)
• This baby: morbidity
• The mother this time
• The next baby
• The mother next time
• Other people’s babies: this is something that we easily forget. What we do with breech affects other mothers and other babies both locally and globally. 

This baby: Death 
The longest section of Lawrence's presentation focused on neonatal & perinatal death. He noted that the longer you drive, the more likely you are to be killed on the motorway. The same is true for pregnancy: the longer you are pregnant, the more likely you will have a stillbirth. If you simply end the pregnancy at 39 weeks, you aren’t exposing any babies to the risk of stillbirth after 39 weeks. (Kind of obvious!) If you “fail” to deliver a baby at 39 weeks, you introduce that baby to a 1/1000 risk of stillbirth.

Lawrence noted that if the only outcome you’re interested in is the prevention of stillbirth—and nothing else—then it is slightly safer for all babies to have a CS at 39 weeks than to wait for labor to begin. The risk of perinatal death for planned cephalic births compared to elective CS is around 1.3/1000 (1/1000 from failing to deliver at 39 weeks + 0.3/1000 intrapartum risk).

Arguments about term breech should be set in this context. Any trial that randomizes babies to elective cesarean section versus labor will expose the baby in the labor group to a slightly higher excess perinatal mortality by nature of waiting for labor to begin and the process of labor itself. This matters because there are other outcomes to take into account, not just perinatal mortality.

Lawrence then addressed the 2000 Term Breech Trial by Hannah et al (TBT). This randomized controlled trial suggested that 1% of babies died because of planned vaginal breech birth. Since it's the only RCT on term breech, the TBT is seen as the definitive answer. However, there are both strengths and weaknesses--"angels and demons" in his words--in this trial. He did not spend too long on them since the literature has already played them out in great detail. But in his view, one of the TBT's major problems was that some of the babies were randomized incorrectly. And the findings of the TBT aren't applicable to a modern setting in many ways; 31% of the babies had no prenatal ultrasound, 13% had no obstetrician in attendance, fetal monitoring was rare, prolonged second stages were allowed, and 10.6% of the babies fell outside the weight range of 2500-4000 g. By Glezerman's analysis, only 16 of the 69 "morbid" babies had outcomes attributable to the mode of delivery.

Lawrence then addressed a number of other influential studies that have influenced the debate over perinatal mortality (PNM) and neonatal mortality (NNM) with regards to breech:

• Meta-analysis by Berhan & Haileamlak (2016). This study suggseted a PNMR of 3/1000 for pVBB vs 0.5/1000 for ECS. However, it was retrospective, heterogenous, and had unstated management and case selection. 
• PREMODA study by Goffinet et al (2006): This multi-center French & Belgian study is a very important series comparing 2502 pVBB and 5573 pCS. It wasn't a RCT, and the two planned arms (VBB vs ECS) aren't directly comparable. The PNMR with planned VBB was 1.2/1000 compared to 1.4/1000 with planned cesarean. To him, this study describes one very important thing: what can be achieved in terms of the safety of VBB. Those breeches were "managed" in a very different way than most people would look after breech births in the UK.
• Vlemmix et al (2014): This population-based study comes from Dutch registry data and looked at 58,320 term breeches from 1997-2007. It is impressive data, and we need to look at it very carefully. All babies were alive at the start of labor, so it eliminated the antepartum stillbirth issue. The important point is the PNMR of 1.6/1000 for pVBB in this study vs the 1/100 quoted in the TBT. 

Overall, there is a difference in PNMR between ECS and planned vaginal birth. However, the TBT has exaggerated the risk of PNM by a factor of 5-10. This influenced his Grade C recommendation in the 2017 RCOG guidelines that put the risk of perinatal morality at 0.5/1000 with CS at 39 weeks, 2/1000 with pVBB, and 1/1000 with planned cephalic birth.

This bears repeating: planned vaginal birth for a head-down baby is twice as dangerous as elective cesarean at 39 weeks--looking only at perinatal mortality--but there is no guideline telling women with head-down babies that vaginal birth is too dangerous! We have to remember this when looking at breech data.

Thus, the 2017 guidelines counseled that "Clinicians should counsel women in an unbiased way that ensures a proper understanding of the absolute as well as relative risks of their different options." Just saying that vaginal breech birth is "four times more dangerous" than an elective cesarean (relative risk) is misleading and doesn't put the numbers in context of their absolute risk.

This raises some important questions: Can the mortality rate be further reduced with VBB? Can we get it down to the cephalic mortality rate? One possible solution comes through better in-labor management; another comes from better case selection.  When looking at small studies that are underpowered to detect mortality, it is reasonable to assume that if the morbidity rate is better, the mortality rate may also be better. This guided his level C recommendation that "Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth."

This baby: Morbidity
Most studies of vaginal breech births show a higher short-term morbidity (usually measured by Apgar scores, NICU stays, and trauma). However, Lawrence noted an "enormous amount of hypocrisy in obstetrics" in how morbidity is interpreted with breech versus VBAC or EFM. For example, VBAC has a 0.08% risk of HIE and 0.04% rate of PNM, yet the RCOG 2015 VBAC guidelines state that "Women considering a vaginal birth after a previous caesarean section can be assured that it is a clinically safe choice for the majority of women." Regarding EFM, neonatal seizures are twice as common with intermittent auscultation than with EFM for low-risk women (Alfirevicz et al 2017), yet intermittent monitoring is still commonplace and accepted for low-risk women.

In other words, obstetrics picks and chooses what risks to downplay and what risks to emphasize, depending on the issue at hand.

The mother this time
Maternal morbidity should also matter to us. It's highly dependent on the emergency cesarean rate. In the TBT, 36.1% of mothers had in-labor cesareans, compared with 29% of women in the PREMODA study and ~45% in the Vlemmix study. A mom with a 95% chance of needing a CS in labor would be best counseled to plan a CS than a mom with a very low chance of needing an in-labor CS. And the chance of an emergency CS is relatively high for a pVBB. Even taking that into account, though, it’s still slightly safer for a mother to plan a VBB than to plan a cesarean for a breech baby.

The next baby
The next baby is also really, really important, especially in other parts of the world where women have large families. There is some data that suggests a two-fold increase in stillbirth for women with a previous CS. That may or not be right; it’s probably more due to the indication for the original CS than the surgery itself.

In the UK, over 50% of women with a previous CS have a repeat CS. Repeated surgeries increase the risk to the mother and to the baby.

We have a really serious responsibility to set an example for other parts of the world. A colleague in Africa told him that for every 1 baby you save by doing a CS for breech, you will kill 5-10 mothers down the road. Just having had a CS makes women much more likely to have other obstetrical problems.

There are also long-term risks to the baby born by cesarean sections, including increased rates of obesity (Darmasseelane et al 2014, Huh et al 2012), type-I diabetes (Cardwell et al 2008), asthma (Huang et al 2015, Black et al 2016), and chronic immune disorders (Sevelsted et al 2015).

Larwrence warned that we are obsessed with the immediate over the long-term, both as parents and as health professionals. We have an obligation not to wreck things in the long-term and not to create disease. It’s very important to bear this in mind and to understand that cesarean section is not a benign procedure.

And there are confounding variables to sort out: how much of the risk comes from the indication versus the cesarean itself?

The mother next time
For a mother with a cesarean scar, there are several increased risks regardless of whether she has a VBAC or a repeat CS for her next baby: blood transfusion, endometriosis, hysterectomy, death, and placenta accreta/percreta.

Other people's babies
Lawrence sometimes jokes with total sincerity: “I want you to have a vaginal breech birth because I need the practice.” Other people's babies are tremendously important, and needing practice is a very reasonable reason to promote vaginal breech birth. In the TBT, low PNMR countries had twice the morbidity during planned VBB than high PNMR countries. Why is this? He theorizes it's because providers in low PNMR countries were less skilled; they had less practice because cesarean section for breech had already become common even before the TBT.

In the UK today, 1/3 of all term breeches are still undiagnosed when labor begins. Until relatively recently, Oxford had a high rate of undiagnosed breech birth. In fact, last year his unit lost 3 undiagnosed breeches who died on the highway en route to the hospital. Providers today don’t know what to do for undiagnosed breech babies. In Oxford, half of them are not diagnosed until full dilation. We need to be able to do a vaginal breech for those 1/3 of all breech babies. This argument is a very, very strong one, Lawrence noted.

Conclusion
Lawrence's presentation raised several important questions about how planned VBB compares to cephalic birth:

• Is it as safe?
• Can it be made as safe?
• How can it be made safer?

This conference should strive to answer those 3 questions.

When looking at breech birth, many outcomes matter, not just perinatal mortality. Short-and long term outcomes matter for both mother and baby. The next baby matters. Other people's babies matter.

Q&A
One audience member mentioned how we calculate stillbirth at different weeks of gestation might affect how we counsel women. She mentioned a different method for calculating stillbirths, taking into account the babies already born, and it makes it more of a flat line vs a sharply increasing line after 40 weeks.

Another audience member asked a question about ECV.

A third person asked whether the cesarean rate for breech had changed after Oxford started doing routine 37 week anatomy scans (which has greatly reduced their undiagnosed breech rate).

Disclaimer: I create these conference summaries from typed notes, not recordings. If something I have written is not accurate, please contact me so I can make the appropriate changes. 

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Helen Lowes: A parent's view on hearing that our baby is breech

Helen Lowes

A parent’s view: Hearing that our baby is breech

North of England Breech Conference, Sheffield

Day 1

A local mother, Helen Lowes, spoke about her daughter born at the Jessops Wing in Sheffield. At 37 weeks, she discovered that her daughter was frank breech. She was booked for ECV and introduced to Helen Dresner Barnes and the Sheffield Breech Birth Service (part of the Citywide 1:1 midwifery team). Helen gave her lots of information about delivering a baby breech. Her ECV was scheduled at 39 weeks, but ultimately she decided to decline it for many reasons.

Helen decided to have a vaginal breech birth but was also booked for a cesarean around the end of her 40th week. However, she had a change of plans and didn’t consent to the CS at 40 weeks. Instead, she pushed it back to 42 weeks. During this time, her daughter changed from frank to complete breech. As her cesarean date loomed closer, Helen changed plans again and pushed the surgery back to 42+6, which was quite unusual.

She was very opposed to induction during her pregnancy, but at this point she began all sorts of natural remedies! But keeping the baby in had some benefits: at 42+2 weeks, she graduated with her 2nd master’s degree. Then she asked if Helen Dresner Barnes and her team would bend or break the rules a little to help her go into labor, and they did. So she had a stretch & sweep at 42+3 and again at 42+5. She went into labor. Ultimately, she dilated to 3 cms and ended up with a cesarean instead of a vaginal breech birth.

What was important to her? Why did she make the choices she did?

For Helen, she wanted to be her; she wanted to have autonomy over her own body. Helen remarked, "When you become pregnant, it’s almost like you have to do everything for the baby." She valued making informed choices, rather than choices made under pressure. "It’s easier to say yes than to say no and to ask why and what are the risks."

Helen made this poignant remark: "You’ll never know the consequences of the option you didn’t take."

She wanted to experience labor. It was important to her, and she was prepared for it. She wasn’t against a cesarean, but she only wanted one when it was needed.

The key word in her journey of having a baby in unusual circumstances was Empowered. "As a woman, you feel that your power is given to your baby. And while you don’t want to put your child at risk, you want to be able to make your own choices." She appreciated Helen Dresner Barne’s sometimes “brutal” honesty; it helped her be able to make choices.

Helen Lowes finished by urging the care providers in the room to can pass on their knowledge about breech so other women can benefit from it.

Comment by Cathy Warwick: Yes, it’s easier to say yes than to say no to what’s offered medically. Even among very well-educated women, they still say things like “Am I allowed to do that?” when it comes to healthcare.

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Cathy Warwick: Personalization, education, and collaboration

Cathy Warwick: Welcoming Remarks

North of England Breech Conference, Sheffield

Day 1

Cathy Warwick CBE is the Chief Executive of the Royal College of Midwives. She opened the North of England Breech Conference with three key points:

1) The policy direction across the UK is embracing personalization of care and maternal choice. This conference is just absolutely critical in terms of personalization. We’ve got a long way to go in fully personalizing maternity care. Of course many people do it brilliantly. But many midwives and doctors think that they do it; however, a lot of what they offer to women is very driven by the needs of their institution or by professional agendas. We don’t really listen properly to what women want and to what they believe is safe for them. We’ve got to think long and hard about what personalized care really means.

She is on a personal mission to eliminate the phrase “women who birth outside of guidelines.” She hates that terminology! When we use that phrase, we put women into a box and say “they’re weird, they’re not normal.” We should stop doing that from this minute onward. [Audience applause] Women are trustworthy and can make their own choices. They are not mad, even if they want things she might not choose.

2) This conference is important in terms of education. We’re often not well-equipped to deliver personalized care. Most midwives and many OBs haven’t seen a vaginal breech birth in their training or practice. So it’s difficult for midwives and OBs to personalize care when they don’t know how to do it well and safely. Lack of education leads to fear, and fear leads to lack of personalization. Hats off to the Sheffield breech team for organizing this conference and for helping to educate all of us to be able to give women the care they deserve.

3) She really admires the multidisciplinary approach at this conference. For a long time there have been individual midwives doing breech births who felt isolated and unsupported. If we work together—midwives and OBs—we are much more able to deliver the care that women really want. When she was working at Kings College Hospital in southeast London, she helped establish a home birth service comprised of ten small teams of midwives. The thing that made her proudest was when the OBs began talking about “our” home birth service. We need to all work together if we’re going to make sure women get the most personalized care.

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Inga is 6 years old!

We had a fun birthday celebration for Inga yesterday. No party or friends, just us. She opened some presents in the morning, one last one at lunch, and planned a delicious dinner. Our little gourmande chose this menu (from Mimi Thorisson's cookbook A Kitchen in France):

• steamed artichokes dipped in cream
• roast chicken with herbs and crème fraîche 
• garden cake

She helped me cook and, of course, got to decorate her cake.



Her entrance into this world was dramatic...the midwife didn't make it in time and she needed some mouth-to-mouth resuscitation.

• Inga's birth story, part 1
• Part 2: Reflections
• Part 3: Resuscitation
• Part 4: Final reflections

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The art of vaginal breech birth on all fours

I recently discovered a new article about upright breech birth: a clinical case report titled The art of vaginal breech birth at term on all fours by Wildschut, Belzen-Slappendel, & Jans. (PDF here).

This article describes a case where a woman planning a hospital birth called her midwife to her home when labor began. Soon after, the midwife discovered an undiagnosed frank breech and the mother had a strong urge to push. Sensing there was not time to transport, the mother decided to remain at home. (This birth took place in the Netherlands, where home birth is still quite common.)

The case report includes a detailed report of the birth. Gorgeous, well-lit photographs document the spontaneous birth of a breech baby with the mother on hands & knees. The birth was completely hands-off except for gentle assistance at the very end. Here are a few sample pictures from the article:

The authors (one of whom was the attending midwife) discuss the challenges of undiagnosed breech presentations, the evidence for all-fours positioning in breech births, and the ongoing debate about whether cesarean or vaginal birth is best for breech presentations. When the authors submitted their manuscript, the Frankfurt study on upright breeches by Louwen et al (full text) had not yet been published; the authors cite a smaller study on upright breech birth by Bogner et al (full text).

At the end of the article, the authors comment:

It remains important that clinicians and midwives are prepared for vaginal breech births. Prerequisites for the effective management of vaginal breech birth include the clinical finding of an average-sized baby (defined as a fetal weight estimate between 2500 and 4000 g), maternal cooperation, and the right mindset of the attending clinician or midwife. In fact, management of a vaginal breech birth is a skill; its safety relies on the competence of the attending health professional. The intrapartum attendant should also be composed and have sufficient confidence and courage to manage vaginal breech birth. For this reason, regular hands-on training sessions with scenario teaching, videos and/or image-based lectures, such as presented in this article, are advocated for health professionals to be acquainted with the various maneuvers for vaginal breech birth.

Undiagnosed breeches still occur regularly. When the attending physician or midwife is not skilled and comfortable with vaginal breech--as is too often the case today--this can pose a risk to both mother and baby. All the more reason for midwifery & obstetrics training programs to continue teaching vaginal breech skills.

For another example of an undiagnosed breech late in labor, read Naomi Carslile's experience while working in a UK hospital. Carlisle, a student midwife, narrates a successful (although much more stressful and anxious) vaginal breech birth. Wildschut and his co-authors show how a well-prepared, calm, and confident birth attendant can make the best of the unexpected.

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Ken Johnsson & Betty-Anne Daviss: The Frankfurt Study

First Amsterdam Breech Conference, Day 2

Ken Johnson & Betty-Anne Daviss

Rethinking the Physiology of Breech Birth: 

A Cohort Study in Frankfurt, Germany, 2004-2011

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

from Spinning Babies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Articles about vaginal breech birth since the Term Breech Trial

Below is a curated list of articles about vaginal breech birth since the 2000 Hannah Term Breech Trial. This is not a comprehensive list, but rather a starting place with some of the more influential articles and studies that have shaped the conversation about vaginal breech birth.

I have not included articles about External Cephalic Version in this list, although ECV remains an important part of managing term breech presentations.

I put this list in chronological order, beginning with the Term Breech Trial. You will also benefit by concurrently reading my breech conference summaries from Ottawa (2009), D.C. (2012), and Amsterdam (2016).

Many thanks to Dutch midwife Miriam Benschop, who is writing a thesis on breech and designing a decision aid for women with breech babies. She contributed many of these references, and I added others that I thought were important.

If you have other studies to suggest, please comment below or email me. I'd be happy to add to this list.

~~~~~

Hannah MME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR (2000).
Planned caesarean section versus planned vaginal birth for breech presentation at term: a
randomised multicentre trial. Turn Breech Trial Collaborative Group, Lancet 356: 1375-83.

ACOG committee opinion: number 265, December 2001. Mode of term single breech delivery. Obstet Gynecol. 98(6): 1189-90.

The Society of Obstetricians and Gynaecologists of Canada. SOGC Statement on Vaginal Breech [press release]. SOGC News 2001 March.

van Roosmalen J, Rosendaal F (2002). There is still room for disagreement about vaginal delivery of breech infants at term. BJOG 109:967–9.

Krebs L, Langhoff-Roos J, Bødker B (2002). Are intrapartum and neonatal deaths in breech delivery at term potentially avoidable? A blinded controlled audit. J Perinat Med. 30:220–224.

Keirse MJ (2002). Evidence-based childbirth only for breech babies? Birth 29:55–9.

Giuliani A, Scholl WM, Basver A, Tamussino KF (2002). Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol. 187:1694–1698.

Hogle KL, Kilburn L, Hewson S, Gafni A, Wall R, Hannah ME (2003). Impact of the international term breech trial on clinical practice and concerns: a survey of centre collaborators. J Obstet Gynaecol Can 25:14–6.

Rietberg CC, Elferink-Stinkens PM, Brand R, Loon A, Hemel O, Visser GH (2003). Term breech presentation in the Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. BJOG 110:604–9.

Gilbert WM, Hicks SM, Boe NM, Danielsen B (2003). Vaginal versus cesarean delivery for breech presentation in California: A population-based study. Obstet Gynecol. 102:911–917.

Hellsten C, Lindqvist PG, Olofsson P (2003). Vaginal breech delivery: is it still an option? Eur J Obstet Gynecol Reprod Biol 111:122–8.

Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A et al. (2004). Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech trial. American Journal of Obstetrics and Gynecology 191: 864-71.

Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M et al. (2004). Maternal outcomes 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. American Journal of Obsterics and Gynecology 191: 917-27.

Su M, Hannah WJ, Willan A, Ross S, Hannah ME (2004). Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial. British Journal of Obstertics & Gyaecology 111: 1065-74.

Kotsaka A. (2004). Inappropriate use of randomised controlled trials to evaluate complex phenomena: a case study of vaginal breech delivery. British Medical Journal 329: 1039-42.

Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME (2004). Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 103:407–12.

Kumari AS, Grundsell H (2004). Mode of delivery for breech presentation in grandmultiparous women. Int J Gynaecol Obstet 85:234–9.

Håheim LL, Albrechtsen S, Berge LN, Bordahl PE, Egeland T, Henriksen T, et al. (2004) Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team. Acta Obstet Gynecol Scand 83:126–30.

Hodnett ED, Hannah ME, Hewson S, Whyte H, Amankwah K, Cheng M, et al. (2005). Mothers’ views of their childbirth experiences 2 years after planned cesarean versus planned vaginal birth for breech presentation at term, in the international randomized Term Breech Trial (PDF). Journal of Gynecology Canada March: 224-31.

Rietberg CCT, Elferink-Stinkens PM, Visser GHA (2005). The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of 35,453 term breech infants (PDF). British Journal of Obstetrics and Gynaecology 112: 205-9.

Verhoeven AT, de Leeuw JP, Bruinse HW (2005). Breech presentation at term: elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children [article in Dutch]. Ned Tijdschr Geneeskd 149:2207–10.

Uotila J, Tuimala R, Kirkinen P (2005). Good perinatal outcome in selective vaginal breech delivery at term. Acta Obstet Gynecol Scand 84:578–83

Pradhan P, Mohajer M, Deshpande S (2005). Outcome of term breech births: 10-year experience at a district general hospital. BJOG. 112:218–222.

Glezerman M (2006). Five years to the Term Breech Trial: The rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology 194: 20-25.

Klein M (2006). Not safer and not cheaper? CMAJ 175(10):1243–6 [Comment re CMAJ 2006;174(8):1109–13].

Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtild D, et al. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology 194: 1002-11. (This is often referred to as the PREMODA study)

Vidaeff AC (2006). Breech delivery before and after the Term Breech Trial. Clinical Obstetrics and Gynecology 49: 198-210.

ACOG. Mode of term singleton breech delivery (2006). ACOG Committee Opinion 340, July 2006. Reaffirmed 2016.

RCOG (2006). The management of breech presentation (PDF). Guideline No. 20b.

Menticoglou SM (2006). Why vaginal breech birth should still be offered (PDF). J Obstet Gynaecol Can 28:380–5.

Sobande A et al (2007). Breech delivery before and after the Term Breech Trial Recommendation (PDF). Saudi Med J 28(8): 1213-1217.

Yamamura Y, Ramin KD, Ramin S (2007). Trial of vaginal breech delivery: Current role. Clinical Obstetrics and Gynecology 50: 526-36.

Schutte JM, Steegers EAP, Santema JG, Schuitemaker NWE, Roosmalen J van (2007). Maternal deaths after elective cesarean section for breech presentation in the Netherlands. Acta Obstetricia et Gynecologica Scandinavia 86: 240-243.

Kotaska A (2007) In the literature: combating coercion: breech birth, parturient choice, and the evolution of evidence-based maternity care. Birth 34:176–80.

Kok M, Gravedeel L, Opmeer BC, Post JAM van der, Mol BWJ (2008). Expectant parents’ preferences for mode of delivery and trade-offs of outcomes for breech presentation. Patient Education and Counseling 72: 305-10.

NVOG (2008). Richtlijn Stuitligging. (2008 guidelines on breech presentation by the Netherlands Association of Obstetrics and Gynaecology)

Deans C, Penn Z (2008). The case for and against vaginal breech delivery (PDF). The Obstetrician & Gynaecologist 10: 139–144. See also this letter to the editor (PDF) by Lucy Bowyer.

Kotaska A, Menticoglou S, Gagnon R, Farine D, Basso M, Bos H, et al.; SOGC Maternal Fetal Medicine Committee. Vaginal delivery of breech presentation (PDF). Society of Obstetricians and Gynaecologists of Canada Clincal Practice Guideline No. 226, June 2009. J Obstet Gynaecol Can 2009;31:557–66. See also a letter to the editor by Hey (PDF).

Lalonde AB (2009). Vaginal Breech Delivery Guideline: The Time Has Come (PDF). Obstet Gynaecol Can 31(6): 483–484

Daviss BA, Johnson KC, Lalonde AB (2010). Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions (PDF). J Obstet Gynaecol Can March: 217-224.

Taillefer C, Dube J (2010) Singleton Breech at Term: Two Continents, Two Approaches (PDF). J Obstet Gynaecol Can 32(3): 238–243. See also these letters to the editor (conversations between the study's authors and Andrew Kotaska & Savas Menticoglou)

Guittier M, Bonnet J, Jarabo G, Boulvain M, Irion O, Hudelson P (2011). Breech presentation and choice of childbirth: A qualitative study of women’s experiences. Midwifery 27: 208-13.

Lawson GW (2011). Report of a breech cesarean section maternal death. Birth 38: 159-61.

Fahy K (2011). Do the findings of the Term Breech trial apply to spontaneous breech birth? (PDF) Women and Birth 24(1): 1-2.

Fahy K (2011). Is breech birth really unsafe? Treatment validity in the Term Breech Trial. Essentially MIDIRS, 2(10): 17-21.

Glasø AH, Sandstad IM, Vanky E (2012). Breech delivery: What influences on the mother’s choice? Acta Obstetricia et Gynecologica Scandinavia 92: 1057-62

Keirse MJNC (2012). Evidence based medicine and perinatal care: From dusk to dawn. Birth 39: 296-300.

Louwen F, Leuchter LM, Reitter A (2012). Beckenendlagengeburt: Mehr als Sectio vs. spontangeburt (Breech Presentation – More than just Caesarean vs. Spontaneous Birth). (2012). Zeitung für Geburtshilfe & Neonaologie 216: 191-4.

Toivonen E, Palomäki O, Huhtala H, Uotila J (2012). Selective vaginal breech delivery at term-still an option. Acta Obstetricia et Gynecologica Scandinavia: 91: 1177-83.

Evans J (2012). Understanding physiological breech birth (PDF). Essentially MIDIRS 3(2):17-21.

Vistad I, Cvancarova M, Hustad BL, Henriksen T (2013). Vaginal breech delivery: results of a prospective registration study. BioMed Central Pregnancy & Childbirth 13: 153-60.

Van Roosmalen J, Meguid T (2014). The dilemma of vaginal breech delivery worldwide (PDF access). The Lancet. 383:183–1864. See also correspondence between Hehir and van Roosmalen.

Vlemmix F, Bergenhenegouwen L, Schaaf JM, Ensing S, Rosman AH, Ravelli ACJ, et al. (2014). Term breech deliveries in the Netherlands: did the increased caesaren rate affect neonatal outcome? A population based cohort study. Acta Obstetricia et Gynecologica Scandinavia 93: 888-896

Borbolla Foster A, Bagust A, Bisits A, Holland M, Welsh A (2014). Lessons to be learnt in managing breech presentation at term: An 11-year single-centre retrospective study. The Australian and New Zealand Journal of Obstetrics and Gynaecology 54: 333-9.

Hunter LA (2014). Vaginal breech birth: Can we move beyond the Term Breech trial? Journal of Midwifery & Women’s Health 59: 320-7.

Zsirai L, Csákány GM, Vargha P, Fülöp V (2015). Breech presentation: its predictors and consequences. An analysis of the Hungarian Tauffer Obstetric database (1996-2011). Acta Obstetricia et Gynecologica Scandinavia 95: 347-354.

Lyons J, Pressey T, Bartholomew S, Liu S, Liston R, Joseph KS (2015); for the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Delivery of breech presentation at term gestation in Canada, 2003–2011. Obstet Gynecol. 125:1153–1161.

Vistad I, Klungsøyr K, Albrechtsen S, Skjeldestad FE (2015). Neonatal outcome for singleton term breech deliveries in Norway from 1991-2011. Acta Obstetricia et Gynecologica Scandinavia 94: 997-1004.

Berhan Y, Hailemiak A (2015). The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies, British Journal of Obsterics and Gynaecology 123: 49-57

Bogner G, Strobl M, Schausberger C, Fischer T, Reisenberger K, Jacobs VR (2015). Breech delivery in the all fours position: A prospective observational comparative study with classical assistance. Journal of Perinatal Medicine 43: 707-13.

Burgos J, Rodriguez L, Cobos P, Osuna C, Mar Centeno M del, Larrieta R, et al. (2015). Management of breech presentation at term: A retrospective cohort study of 10 years of experience. Journal of Perinatology 35: 803-8.

Davidson J. (2015). The experience of vaginal breech birth. A social, cultural and gendered context (PDF). PhD Thesis, University of Brighton.

Hofmeyr GJ, Hannah M, Lawrie TA (2015). Planned caesarean section for term breech delivery. Cochrane Database Systematic Review. CD000166.

Homer CSE, Watts NP, Petrovska K, Sjostedt CM, Bisits A (2015). Women’s experiences of planning a vaginal breech birth in Australia. BioMed Central Pregnancy & Childbirth 15: 89-96.

Joseph KS, Pressey T, Lyons J, Bartholomew S, Liu S, Muraca G, et al (2015). Once more unto the breech. Obstetrics & Gynecology 125: 1162-7.

Powell R, Walker S, Barrett A (2015). Informed consent to breech birth in New Zealand (full text). The New Zealand Medical Journal 24 July 2015; 128(1418): 85-92. PDF link here.

RANZCOG (2016). Management of breech presentation at term (PDF). Royal Australian and New Zealand College of Obstetricians and Gynecologists.

Petrovska K, Watts NP, Catling C, Bisits A, Homer CSE (2016). Supporting women planning a vaginal breech birth: An international survey. Birth 43: 352-357

Petrovska K, Watts NP, Catling C, Bisits A, Homer CSE (2016). “Stress, anger, fear and injustice”: An international qualitative survey of women’s experiences planning a vaginal breech birth. Midwifery 0: 464–469.

Walker S, Scamell M, Parker P (2016). Standards for maternity care attending planned upright breech births: A Delphi Study. Midwifery 34: 7-14.

Walker S, Scamell M, Parker P (2016). Principles of physiological breech birth practice: A Delphi study. Midwifery. Dec;43:1-6.

Bin YS, Ford JB, Nicholl MC, Roberts CL (2016). Long-term childhood outcomes of breech presentation by intended mode of delivery: a population record linkage study. Australian and New Zealand Journal of Obstetrics and Gynaecology 56: 453-59.

Louwen F, Daviss BA, Johnson KC, Reitter A (2017). Does breech delivery in an upright position instead of on the back improve outcoms and avoid cesareans? (full text) International Journal of Gynecology & Obstetrics 136: 151-161.
* Note: Clicking on "supporting information" on the right side bar will allow you to view an upright breech birth at Dr. Louwen's clinic.

Forthcoming article by Vlemmix F et al about long-term effects of mode of birth for breech, specifically what happens to the mother's next baby after her breech baby (mentioned in Dr. Thomas van den Akker's presentation Who Pays the Price? at the 2016 Amsterdam Breech Conference).

I also recommend Shawn Walker's website; she updates about her breech workshops, demonstrates techniques and maneuvers, and explains the principles of physiological breech birth.

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La parturiente et la marathonienne

La parturiente et la marathonienne

Texte de Rixa Freeze: Labor and Marathons

Traduction: Manon Wallenberger

Manon Wallenberger travaille comme berger et écrivain indépendant pour L'alpe, La revue Z et Zalp. Elle a vécu les joies d'une naissance naturelle il ya quelques mois et elle la faire encore!

Manon Wallenberger works as a shepherd and a free-lance writer for L'alpe, La revue Z and Zalp. She has been through the joys of a natural birth a few month ago and wants more of it!

I want to give a big thank-you to Manon for translating this essay! Je voudrais bien remercier Manon pour la traduction!

"Mike" Michael L. Baird

Avertissement : Si jamais quelqu’un a envie de poster un commentaire indigné pour dire qu’accoucher et courir un marathon ce n’est PAS la même chose, qu’il lise d’abord ceci. Evidemment que ce n’est pas pareil. Evidemment l’analogie ne fonctionne plus passé un certain stade. Je pense que la plus grande différence entre donner la vie et courir un marathon c’est qu’accoucher est quelque chose de que toute femme est capable de faire, alors que courir un marathon est, je l’admets, un sport d’endurance extrême.

Je me suis souvent demandé pourquoi on n’aborde pas la grossesse, l’accouchement et la naissance comme s’il s’agissait de courir un marathon. Les femmes enceintes sont confrontées à tant de peurs et de propos alarmistes : « Votre bébé pourrait être trop gros ou trop petit. Vous pourriez être atteinte d’une toxémie. Vous prenez trop de poids ou pas assez. Vous pourriez mourir d’une hémorragie. Vous avez peut-être le pelvis trop étroit. La tête de votre bébé pourrait rester coincée. Il pourrait être en détresse grave. Vous ne saurez probablement pas gérer la douleur, donc il faudrait envisager la péridurale. On ne vous donnera pas de médaille pour avoir accouché de manière non médicalisée. De toute façon tout ce qui compte c’est d’avoir un bébé en bonne santé. »

Et si nous abordions le marathon avec autant de pessimisme que nous le faisons lorsqu’il s’agit de l’enfantement ? Voici mon scenario imaginaire vécu par Anne, aspirante marathonienne.

Anne était assez en forme et capable de courir plusieurs kilomètres, à un rythme, certes, assez lent. Elle faisait du cross au lycée et aimait ça, même si elle était souvent une des dernières à franchir la ligne d’arrivée. Plusieurs amis qui avaient récemment couru des marathons lui en donnèrent l’idée : elle décida de s’y préparer.

Anne commença par se documenter sur la manière de réussir un marathon. Elle voulait trouver des calendriers d’entraînement, connaître les besoins nutritionnels des coureurs et avoir des conseils sur le choix des chaussures de course. Elle alla à la bibliothèque municipale qui avait une étagère pleine de livres portant tous sur les risques liés au marathon. Les différentes blessures dont les coureurs étaient souvent victimes étaient traitées en détail, alors que les réussites n’étaient abordées que succinctement. Les livres vous prévenaient bien que courir le marathon peut certes vous procurer un sentiment de force mais que la plupart des gens ne sont ni capables de s’astreindre à l’entrainement nécessaire ni de terminer la course. Les livres insistaient également sur l’énorme souffrance physique que les coureurs enduraient. Anne savait que des blessures pouvaient arriver et même si elle trouvait cette information intéressante, elle préférait en savoir plus sur la façon de les éviter en s’entrainant correctement, en faisant des étirements ou en modifiant son régime alimentaire. Elle avait aussi plutôt envie de lire des livres qui la motiveraient en partant du principe qu’on pouvait y arriver, plutôt que l’inverse.

Elle se dit qu’il devait bien y avoir quelque part des informations plus utiles, donc elle prit une chaise et s’installa face à l’ordinateur de la bibliothèque. Elle s’échina sur des pages et des pages de résultats avant de tomber sur une communauté de coureuses, peu nombreuses mais sachant se faire entendre, qui avaient réussi leur course et l’évoquaient avec ravissement. Leurs récits parlaient dans leur ensemble de triomphe, de confiance en soi et d’euphorie. Elles parlaient des heures de préparation mentale et physique, des recherches poussées qu’elles avaient faites pour s’assurer d’être parfaitement en forme, et pour trouver les moyens de prévenir les blessures classiques comme les fissures du tibia, ou les problèmes articulaires. Elles se soutenaient mutuellement lorsque l’une d’entre elles n’avait pas réussi à atteindre le temps qu’elle s’était fixée, ou lorsqu’un problème physique l’obligeait à s’arrêter en route. Elles s’encourageaient à mesure qu’approchait le jour de la course.

Anne accrocha son programme d’entraînement à plusieurs endroits de la maison afin de le voir tous les jours. Elle décida de rester positive, sachant que les meilleurs athlètes considèrent la préparation mentale aussi importante que l’entraînement physique. Chaque jour elle consacra du temps à la méditation et à la visualisation. Elle imaginait ce qu’elle ressentirait sur la ligne de départ, en attendant le coup de pistolet du starter. Elle visualisait son cœur qui cognait dans sa poitrine, son sang qui fournissait de l’oxygène à ses muscles, son souffle mesuré et régulier. Elle se répétait des affirmations positives comme : ce sera intense et parfois difficile, mais je sais que je peux le faire.

Quelques semaines plus tard l’entraînement d’Ann se déroulait bien. Elle avait sauté quelques jours, mais la plupart du temps elle atteignait ses objectifs quotidiens. Même si courir était parfois ennuyeux et pénible elle adorait les sensations que cela lui procurait après coup. Anne raconta à une amie qu’elle s’entraînait pour un marathon et fut surprise lorsque celle-ci lui raconta une foule de récits horribles sur des marathoniens qui souffraient à vie de leurs blessures- et même l’histoire d’un coureur qui avait bu tellement d’eau pendant la course qu’il en était mort. Anne répondit qu’elle s’était renseignée sur les blessures classiques ou plus rares, et qu’elle était sûre qu’elle pourrait soit les prévenir, soit se soigner toute seule, ou demander de l’aide si le cas était grave. Son amie lui dit : « mais comment peux-tu en être sure ? Tu pourrais mourir d’une attaque cardiaque pendant la course- tu n’aurais aucun moyen de le savoir avant que ça n’arrive. Ca ne vaut vraiment pas la peine de courir le risque. »

La famille d’Anne pensait qu’elle était folle. Ne devrait-elle pas employer son temps à une activité plus utile ? Et si quelque chose tournait mal ? Et si pendant la course elle avait trop mal et ne pouvait finir, comment se sentirait-elle ? Anne répondit à sa famille qu’elle s’était renseignée et que c’était une chose importante pour elle. Elle leur demanda soit de lui parler de sa future course de manière positive, soit de se taire.

Anne remarqua que les médias se concentraient toujours sur les récits à sensation de courses qui tournaient au drame. Lorsque des journaux télévisés couvraient un marathon, ils montraient des coureurs qui avançaient en boitillant avec des airs de morts-vivants. La plupart du temps ils n’interviewaient que des coureurs ayant abandonné la course, leur accordant plusieurs minutes à l’antenne pour raconter leurs récits. Puis, comme à regret, ils donnaient 30 secondes à un coureur à la mine ravie, malgré la fatigue et la sueur. Bien sûr, une fois que ce coureur là avait terminé son récit, le présentateur rappelait aux téléspectateurs que la plupart des gens sont incapables de courir un marathon et qu’il valait mieux faire taire ses espoirs. Bon sang, pensa Anne. Je connais pourtant plein de gens qui ont terminé la course sans mourir, se casser une jambe ou finir handicapés à vie.

Sans qu’elle sache trop comment- peut-être lorsqu’elle avait commandé quelques paires de ses baskets préférées- des entreprises qui sponsorisent les marathoniens se procurèrent son adresse. Tous les jours ou presque, elle trouvait dans sa boite aux lettres une nouvelle pub sur papier glacé pour « le marathon sans douleurs et sans efforts ». Le slogan d’une des entreprises était : « Nous faisons le boulot pour vous-il vous suffit d’être là pour la course. » Dans leur brochure Anne apprit que :

C’est un énorme travail de courir un marathon. La douleur est insoutenable. Les risques que représentent tant de kilomètres à parcourir sont nombreux. Pourquoi souffrir si vous pouvez le faire avec Indol™? Pour seulement 12 versements mensuels de 199 dollars vous pouvez terminer votre marathon confortablement et avec élégance dans notre véhicule motorisé breveté Indol™. Notre chauffeur vous récupèrera personnellement dès que vous aurez trop mal. Une fois installé dans le confort luxueux de votre siège-Couralaiz™, vous pourrez savourer le spectacle qu’on vous conduit jusqu’à la ligne d’arrivée. Vous recevrez une photo gratuite vous représentant en train de franchir la ligne d’arrivée à pied. Boissons non inclues. Les coureurs devront s’acquitter d’une somme de 10 dollars par kilomètre parcouru à pied. Vous en êtes dispensé si vous prenez l’option Couralaiz™ dans les 5 premiers km. Pour des raisons de responsabilité civile, l’option Couralaiz™ ne peut être souscrite ni pour les 4 premiers km ni après le 23ème.

Anne empilait ces publicités près de sa cheminée. Après ses longues courses du samedi, elle se faisait couler un bain bien chaud, allumait la cheminée et les jetait dans les flammes en observant les bords qui tournoyaient et se recroquevillaient. Elle imaginait ses peurs en train de fondre et de disparaître avec ces publicités luxueuses.

L’entraînement d’Anne se poursuivait. Elle aimait sentir son corps changer- voir ses cuisses se raffermir, sentir les articulations jouer entre chaque ensemble de muscles. Se préparer pour la course lui permit également de mieux apprécier une nourriture saine et nutritive. Son corps lui réclamait des protéines, des fruits frais, des légumes et des hydrates de carbone complexes. Elle mangeait des sucreries de temps en temps mais ne les appréciait plus autant qu’avant.

Plusieurs mois après avoir commencé son entraînement, Anne entendit parler avec inquiétude d’une nouvelle mode dans le monde du marathon : la fracture choisie (FC). Elle savait que les fractures liées au stress faisaient partie des blessures courantes dans le monde de la course, sans parler des fractures rares mais sévères liés à des chutes accidentelles. Apparemment certaines personnes vantaient un nouveau « traitement préventif » qui consistait à porter des moniteurs de fracture osseuse pendant la course. L’argument publicitaire pour ces moniteurs était qu’ils étaient censés prévenir la fracture avant qu’elle n’arrive. En utilisant les informations transmises par les moniteurs, des chirurgiens pouvaient alors finir de casser l’os avec soin (pour s’assurer d’avoir une fracture nette et franche) et de le réparer dans un environnement sécurisé. Les moniteurs étaient assez lourds, et causaient parfois des chutes chez les coureurs, entraînant des blessures importantes. Pourtant, elles étaient LE nouveau must dans le monde de la course où on les présentait comme « le filet de sécurité du coureur ». Un chirurgien vantait cette technologie qui rendait les os des jambes « plus solides que des neufs ». Le monde est-il devenu fou, se demanda Anne. L’idée que des gens pouvaient choisir de se faire casser des os avant même d’avoir un sérieux problème la dépassait complètement. Des flyers commençaient à arriver dans sa boite aux lettres décrivant la FS. Anne ne put s’empêcher de sourire lorsqu’elle découvrit qu’une de ces entreprises s’appelait FCMQN : fracture choisie, mieux que du neuf.

Alors que le jour de la course approchait, Anne était partagée entre la confiance et l’agitation. Elle savait qu’elle s’était bien préparée, mais elle n’avait encore jamais couru 42 km. Elle décida que si quelque chose tournait mal pendant la course et l’empêchait de finir, elle l’accepterait calmement, sachant qu’elle aurait fait tout ce qui était en son pouvoir pour réussir. Tous les jours, elle continuait à se projeter mentalement, s’imaginant à quel point il serait valorisant de terminer la course. Celle-ci finissait dans une vallée où coulait une rivière. Anne y allait souvent nager et savait qu’elle se sentirait incroyablement bien dans l’eau fraiche après l’effort. Elle garda en tête cette image d’elle-même allongée sur le dos, flottant dans l’eau claire, le corps suspendu entre le ciel et l’eau.

Le jour de la course, Anne fut surprise de la foule qu’il y’avait autour des tentes où s’inscrivaient les coureurs. Il y’avait quasiment autant de sponsors que de coureurs. Elle parla avec un coureur expérimenté qui lui dit que cela ne s’améliorerait pas, même après le départ de la course. Elle verrait des motards rouler à côté des coureurs en leur demandant de dire à quel point ils souffraient, et s’ils voulaient abandonner. Sur le trajet, des spectateurs brandiraient des panneaux où on pourrait lire :

• Il n’est jamais trop tard pour abandonner
• Ce n’est pas parce que tu finiras la course que tu auras une médaille
• Lâche ou crève

Alors qu’elles attendaient dans la file pour s’inscrire, une femme qui prenait aussi le départ et avait couru son premier marathon jusqu’au bout l’année précédente, lui donna un paquet. C’était un t-shirt avec le slogan : Zone de non drogue. « Tu vas en avoir besoin, lui dit-elle, surtout autour du km 35 lorsque les sponsors te tendront des cachets de morphine. Ils savent qu’il vaut mieux laisser tomber ceux qui portent ce t-shirt, ou alors ils vont se faire ramasser et à l’occasion se prendre un coup de poing bien placé ». Anne fit un large sourire.

Tout en faisant ses étirements, elle se concentra, visualisa les différentes étapes de la course et se répéta ses mantras : Je peux le faire. Je suis forte. Je suis prête.

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

First Amsterdam Breech Conference, Day 2

Andrew Bisits

Establishing a training course in breech vaginal birth in Australia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

~~~~~

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

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

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

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

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First time skiing for Inga and Ivy

Friday evening we decided, "Let's go skiing tomorrow!" We packed the car full of boots, skis, coats, pants, and mittens and drove up to Auron. The ski resorts near us haven't got much snow yet, and the lower hills were all man-made snow.

Still it was great to get the whole family on skis for the first time. Ivy and Inga had never been, and it was my first time skiing for 12+ years...thanks to being pregnant or breastfeeding or both ever since Zari was born.

Ivy loved it.



Inga, on the other hand, had a rough day. She was still recovering from a horrible GI bug she got on Tuesday morning. We thought she was on the mend...then she puked once in the car and again when we were getting our boots on. Eric took her on the slopes for an hour or two, and she was a sobbing mess by the end. I took her into a restaurant that was kind enough to let us camp out--there aren't communal ski lodges in France, just individual restaurants and cafes. She had diarrhea and then immediately fell asleep on a few chairs for the rest of the afternoon. She hadn't eaten anything all day, poor thing, and very little since Tuesday.



But she's acting normal today for the first time in almost a week. Normal = talking nonstop, jumping around, being obstinate, running, and eating.

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Back in France

3 days after Christmas, we packed up our house, loaded 6 suitcases, 1 violin, 1 duffel bag, 4 backpacks, and 4 children into a friend's minivan, and flew to France.

We'll be in Nice until the end of the summer. Why? Well, 300 days of sunshine + ocean + Mediterranean climate is a good enough excuse. But we're here primarily so I can work on my breech projects with Shawn Walker. I'm continuing to interview US providers and administrators while I'm over here.

We're both taking a half-year unpaid leave of absence to make it work. Some day, I would love to get paid for the work I do in maternity care...Anyone want to hire me?

Adjusting to the new time zone was brutal for Eric and me this time. And just when we felt back to normal, Inga got really sick. I've never seen anything like it in my 10+ years of parenting. She threw up nonstop for 24 hours, at least 20-30 times. The next day she started sipping electrolyte solution and even ate some applesauce by dinnertime. Today she's still down with a fever and quite weak.

Fortunately Inga is the happiest sick child ever. She's super chipper and never cried or complained about throwing up so much. She even loved it when she threw up juice: "Look it's pink! And it tastes good! I hope I throw up juice again!"

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

First Amsterdam Breech Conference, Day 2

Anke Reitter

New Insights from Pelvimetric MRI Studies

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

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

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

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

Pelvimetry & Primip Breech

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

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

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

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

MRI study on maternal position & pelvic diameters

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

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

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

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

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

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

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

How do we put all this into practice? 

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

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

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

Signs of normal & abnormal rotation with a supine breech:

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

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

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

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

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

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

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

~~~~~

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

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

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Merry Christmas from the Freezes!

Christmas still happened, despite last-minute renovations, packing, and cleaning. (We're heading back to Nice until mid-July and getting the house ready for our new renters.) Warm weather and sunshine, here we come!

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