Friday, March 03, 2017

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.

Read more ...

Thursday, February 09, 2017

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.
Read more ...

Wednesday, February 08, 2017

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)

Read more ...

Thursday, February 02, 2017

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.

Read more ...

Tuesday, January 24, 2017

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'alpeLa 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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Wednesday, January 18, 2017

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.

• 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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Sunday, January 08, 2017

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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Thursday, January 05, 2017

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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Tuesday, December 27, 2016

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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Sunday, December 25, 2016

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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Tuesday, December 20, 2016

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

First Amsterdam Breech Conference, Day 2
Leonie van Rheenen
Free choice in birth position, change of practice…
An obstetrician's point of view

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

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

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

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

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

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

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

She thought about it. She went through several stages as she considered whether she was okay with attending a breech birth on all fours--something she had never done before:
1. No, never, it's impossible!
2. I don’t see any advantages. Why is it better?
3. How can I learn? How can I get enough experience?
4. What if…
She started to think, There isn’t really evidence for being on your back; it’s more tradition than anything else. But how am I ever going to learn to do breeches on all fours? And on top of that, she was thinking, How can I tell this mom that I’ve never done it before and only have seen it on YouTube?!

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

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

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

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

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

Leonie ended with some advice: the next time you have the opportunity to see an upright breech birth, keep these two things in mind:
  • The laboring woman knows best
  • You can do it! It’s not so difficult. Worst case, if you feel a bit lost, you can always turn her around and put her in stirrups if that’s how you’ve been trained. You have to start somewhere.

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

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

Interested in Leonie's work? You can follow her on Twitter.
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Monday, December 19, 2016

Frank Louwen: Maneuvers for resolving complicated breech birth

First Amsterdam Breech Conference, Day 2
Frank Louwen
Maneuvers for resolving complicated breech birth

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

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

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

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

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

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

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

Expect and compare. That is the most important thing.

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

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

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

Illustration from Louwen et al. 2016

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

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

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

Detect the problem and remove the situation.

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

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


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

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

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

First Amsterdam Breech Conference, Day 2
Jane Evans
Mechanisms of (Upright) Breech Birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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