Pearls & Sand in Amsterdam, Part 2

Before I begin discussing the talks from Day 2 of the First Amsterdam Breech conference I want to give a huge shout out to my friend, Rixa Freeze. Her Stand and Deliver blog has put together an in depth summary, almost a play by play, if you will, of the whole conference. Please take a look for another perspective.

 with Anke Reiter

with Anke Reiter

Day 2, Friday July 1, 2016 began with a talk titled, “New Insights from pelvimetric MRI studies” from Anke Reitter, MD PhD, another renowned MFM specialist from Frankfurt, Germany. Anke calls herself a breech activist and wears it as a badge of honor. In 2004, her facility had 70 breech clients which climbed to 145 in 2012. Of those 70% were primiparas. In my own practice, 86% of my laboring breech clients are primips. This number makes sense since the success of ECV is so much greater in multips. It also highlights the problem with breech training programs that automatically exclude the primip breech. The group that most needs this service to avoid that first cesarean section.

breech slide

Among the selection criteria used in the Frankfurt breech study mentioned below is pelvimetry. The Van Loon study from The Lancet, 1997 showed that MRI pelvimetry made no difference in cesarean rate from those randomized to pelvimetry vs. no pelvimetry. But it did show a lower emergency cesarean rate in the known group. The Frankfurt study did use MRI pelvimetry as part of their methodology. A measurement of <12 cm for the obstetrical conjugate (OC, measured from the promontory of the sacrum to a point a few millimeters from the top of the pubic symphysis) resulted in recommendation for cesarean. They had a 53.2% success rate in primips attempting labor who met these criteria. While I truly understand the need for scientific studies to set margins and limits I find it a bit distressing that very possibly a woman with an OC of 11.9cm would not be allowed a trial of labor in this black and white world.

Fortunately, I think the researchers here were asking some very important questions about the use of MRI as strict inclusion/exclusion criteria. One of these questions is, “What effect does position have on pelvic dimensions?” Most MRIs are taken in the supine position. This is not the way breech delivery is currently recommended. We know the pelvis is a dynamic structure. The pelvic inlet decreases slightly with squatting. The pelvic mid-plane and outlet increases with squatting. And the transverse diameter does open with squatting. All these findings support the use of the upright position for breech birth and Dr. Reitter closed by saying, “Our MRI study does not justify the routine use of clinical pelvimetry.” This has been a consistent theme of mine. Most women deserve a trial of labor and with a healthy term breech delivery the experts all agree that if the mother can deliver the baby’s bottom the rest will follow. Term breech delivery succeeds or not for the same reasons as cephalic delivery does.

Next we had a talk from Andrew Bisits, MD, PhD on establishing a training course in vaginal breech birth in Australia. I did not take a lot of notes here because I was intent on watching the visuals presented. But they have a 58% success rate in his institution. My own primip breech success rate is 81% and although my numbers are not large enough to reach statistical significance I do believe they support my hypothesis that, like all births, odds of a successful vaginal birth improve when women are allowed to labor as they desire in a nurturing environment as is often found in the home, not the hospital. (I should say that none of the experts I spoke to were willing to concede that breech birth should be done anywhere but in the hospital. This was not surprising in the least.)  Dr. Bisits also discussed maneuvers for a nuchal arm and suggested turning the baby toward the direction the hand would be pointing. Gluteal lift and pushing mom forward when on all fours will also make just a bit more room to assist the delivery. Attending a conference or training course is the best way to visualize and learn these techniques as words just cannot do them justice. I was grateful to Dr. Bisits and the many experts who supervised a lunchtime hands on training session with some very lifelike mannequins.

After lunch came Shawn Walker, BSc.MA, Midwife at City University, London. She emphasized the need for breech specialty clinics. Her desire is to make vaginal breech safer and words of wisdom such as “Respect the mechanism when normal, restore the mechanism when not.” were spoken. Shawn recommends that once the umbilicus is born the head should follow in less than 5 minutes. Others say 3 minutes. I have had to adjust the way I do breech deliveries as I was always taught hands on and now it is pretty clear that unless the baby is telling you it wants assistance then it is hands off. Although 5 minutes may seem like a long time there are ways to assess fetal wellbeing during that time. I use color, tone, vitality of the cord and capillary filling. When the arms are in a good position the baby will have its chest facing you, not rotated, and chest cleavage (valley of the cord) is a good sign, meaning that both arms are down in front of the baby. A baby that is to the chest and rotated away from transverse needs assistance.

We were told that 55% of breeches come in right sacrum anterior (RSA) and the 45% who enter on the left are somewhat more likely not to rotate and require assistance. Try not to flick out the legs because it may interfere with the baby’s normal movements. The goal is to get the shoulders to be transverse to the pelvic inlet. Once they are transverse the baby will deliver. While holding the shoulders, if possible, you can rotate the baby 180 degrees toward the nuchal arm and then back 90 degrees while the uterus is relaxed between contractions. Frank breech is the most normal breech position with the least pathology.

Leonie van Rheenen, MD from the Netherlands spoke next on, “Free choice in birth position, change of practice. An obstetrician’s point of view”. Her lecture was clearly meant for hospital based birthing as it should be since 99% of the diminishing breech births are born there and not at home. Yes, I know I’m an outlier. In today’s world of decreasing volume of breech it is not reasonable to expect most practitioners will have enough actual births so we must increase training with simulators, models, computer technology, reflection and discussion in order to regain sensible confidence. She suggests an informed consent video. I like to use the documentary, “Head’s Up, The disappearing Art of Breech Delivery”   as a good starting place for all of my new breech clients. ECV should be discussed as a part of the informed consent process. We all have our biases and we should do our best to contain them but should make them known to our clients. Discuss the course of a breech labor including options for pain relief and augmentation, or not. For institutions that require continuous fetal monitoring, telemetry would be ideal. Clients should be shown as many videos of a breech birth as they desire.

It is so important to create local safe spaces for physiologic breech birth. It is crazy for mothers to have to travel long distances for what is so often a normal birth in skilled hands. Breech skills can be taught and should be taught just as we teach skills for shoulder dystocia.
 With Betty Anne Davis and Frank Louwen

With Betty Anne Davis and Frank Louwen

Finally, the last lecture of the conference focused on The Frankfurt Study and was presented by Ken Johnson, PhD, senior epidemiologist and Betty-Anne Daviss, RM, MA adjunct professor and registered midwife, both from Ottawa, Canada. This study is an observational cohort study and was the first to really analyze a standardized delivery method (upright) for breech birth. As opposed to the TBT which made use of composite risk (see some of my previous blogs and LTEs on the flaws of composite risk), studies that look at cohorts in institutions with skilled attendants have much more positive results.  The Frankfurt Study looked 750 women > 37 weeks from 2004-2011. If ECV was chosen and unsuccessful then MRI was performed. Most of these women were primiparas. A cesarean was done for an obstetric conjugate <12 cm or a fetus with EFW <2000 gm. VBACs were included in the study. They used an intention to treat model when comparing cesarean to vaginal because they could not compare planned upright vs. lithotomy as decisions in the moment can change as labor progressed.

Of the 750 women, 315 (42%) had planned cesarean section. Half requested cesarean and half did not meet vaginal criteria. 75% of the planned cesarean women were primips while 67% of the planned vaginal breech birth (VBB) group were primips. Of the laboring women, 40 were in lithotomy and 229 were upright.

                                                      All VBB Attempts                                Strictly Upright VBB Attempts

Overall Success:                                       62.3%                                                          66%

Primips:                                                     55%                                                              56%

Multips:                                                     78%                                                              83%

Of those that delivered upright 38.4% required maneuvers where 77.5% of the lithotomy mothers did. No forceps or episiotomies were used. There were no anomalies or neonatal deaths.  Upright mothers also had a shorter second stage when compared to lithotomy, 62 minutes vs. 106 minutes. (Second stage being defined as full dilation, not active pushing).

Like a good study should, this one adds information to the debate on VBB. Unlike the TBT seems to suggest, this debate is far from over. Ultimately, whatever we think as practitioners and institutions the decision of how to birth a baby does not really belong to us. It belongs to the respected and well informed mother. My take home message from this gathering of wonderful people supports my initial understanding that properly selected term breech delivery in skilled hands remains a reasonable option. And that it is the duty of academicians, whatever they may personally believe, to pass on these skills to the next generation of practitioners. For a surprise breech is something every practitioner will likely face in their career and not knowing what to do will certainly be the biggest tragedy. This conference also reinforced the importance of collaboration and respect between midwife and obstetrician and between academic world and those of us out in the other real world. It is important to remember that two individuals, given the same information, should not be expected to reach the same conclusion.

Thank you to the organizers of this event. You did a marvelous job. I am most appreciative of your hospitality and of your beautiful city. I can’t wait to do it again.

Warmly, Dr. Fischbein