Debate: Is breech pathological or a variation of normal?

Marek Glezerman and Betty-Anne Daviss, Moderated by Ken Johnson

After two intense days of learning and discussion, we were all ready to let our hair down a bit. Dr. Marek Glezerman and Betty-Anne Daviss engaged in a debate that was both earnest and hilarious. Ken Johnson (Betty-Anne's husband) heckled his wife for wearing "attire unbecoming a midwife" (she was dressed in asymmetrical layers of purple and green, evoking a tree sprite) and for unfairly influencing the audience when she signaled Dr. Andrew Bisits to stand up and begin playing his violin. But behind the silliness was an earnest question: is breech pathology or simply a variation of normal? What are the implications for how we understand and categorize breech?

Marek Glezerman opened the debate, arguing that the answer to this question has consequences. Why should he enter this mine field of a questions? If you want to struggle for the right cause, you should address the existing concerns by refuting them or handling them.

Personal experience isn't a very scientific place to start, but it's still important. He started his residency 39 years ago and has since headed three OB/GYN departments. Over those years, he's been the chair for around 200,000 deliveries. The chairman's position is important because all adverse outcomes eventually land on his desk.

He next discussed several studies on breech presentations:

• Schutte et al, 1985 compared malformations between breech and vertex presentations. They found more malformations at each gestational week with a breech presentation than with a vertex. Schutte observed: "It may be that breech presentation may not be coincidental but rather a product of the quality of the infant...if there is some truth in this supposition, it is unlikely that medical intervention ... can improve the outcome." (Schutte MF, van Hemel OJS, van de Berg C, van de Pol A. Perinatal mortality in breech presentations as compared with vertex presentations in singleton pregnancies: an analysis based upon 58,189 computer-registered pregnancies in The Netherlands. Eur. J. Obstet. Gynecol. Reprod. Biol. 19 (1985): 391-400.)
• Breech delivery is associated with more anomalies and higher mortality rates, irrespective of delivery mode. Remember that association is not necessarily causation. About 20% of breech presentations can be explained by these anomalies; the rest are unexplained. Breech presentation is an independent risk factor for neurological pathology and cerebral palsy, irrespective of mode of delivery.
• Ochschorn et al, 2009: found that length and coil numbers in the umbilical cord were different in breech vs. vertex presentations. The cords were shorter (57 v 64) and had fewer coils (5 vs 12). We don't know the significance of this phenomenon, just that it exists. (Ochshorn Y et al. Coiling characteristics of umbilical cords in breech vs. vertex presentation. J Perinat Med. 37.5 (2009):525-8.)
• Another interesting study by Sekulić et al found decreased expression of fetal movements in the first few days of life in breech presenting babies (all born via CS) which cannot be explained by anything else. We don't know the important or reasons behind this phenomenon. He'd love to see more long-term studies of breech babies vs. cephalic babies in all aspects. (Sekulić S. et al. Decreased expression of the righting reflex and locomotor movements in breech-presenting newborns in the first days of life. Early Hum Dev. 85.4 (Apr 2009):263-6.)
• Haruta et al compared breech and vertex babies born by elective cesarean. The breech presenting babies had lower umbilical arterial oxygen levels, more hypoxemia, and lower 1 minute Apgars. (Haruta M et al. Umbilical blood-gas status at cesarean section for breech presentation: a comparison with vertex presentation. [Article in Japanese] Nihon Sanka Fujinka Gakkai Zasshi. 41.10 (Oct 1989): 1530-6)
• Kean et al found that breech babies at term had more state transitions in utero than vertex babies. They concluded that "breech babies are different." (Kean LH et al. A comparison of fetal behaviour in breech and cephalic presentations at term. Br J Obstet Gynaecol. 106.11 (Nov 1999): 1209-13.)

Conclusion:
We know that breech babies are different. What is the key to that lock? Is it a cesarean? Glezerman argued no--there's no connection between mode of delivery and these differences. So is breech a variation of normalcy? No. Is it pathology or associated with pathology? Sometimes yes, but not all of the time. But we can say that "Breech babies are different."

Breech presentation is not a variation of normalcy; that's using the wrong tool for the right goal. Breech presentation may be the result, not the etiology, of pathology. Patients need to be informed, and courts need to be informed. A persistent breech presentation may need special attention. But cesarean section is no panacea.

We need more long-term prospective data on babies born breech and on persistent breech presentations. We also need to distinguish between statistical and clinical significance. There are many statistical significances in breech presentations that have no clinical significance.

Betty-Anne Daviss asked: Whom does pathologizing the breech serve best? Whom does it harm? To answer that question, she outlined the "3 Ps of corporate global society": Privatize, Professionalize, and Pathologize. (This was a play on words on the 3 P's of birth: Passenger, Power, and Pelvis.)

1. Privatize: World Trade & World Bank
Our world is seeing increased privatization of education and health care. Health care has become a big business, and interventions are sold as commodities. She discussed the 2012 WHO report by Lauer et al on what drives demand for cesarean section. Are cesarean rates rising because of women's choices? They found that the demand-side model is much smaller than previously reported. the supply-side model has some modest effects on cesarean rates; the more it's available, the more it will be used. But they found that health system factors have the largest impact on cesarean utilization rates. These factors are institutional and related to the legal environment in which health-care decisions are made. They concluded that the debate about patient choice vs. doctors' preferences isn't the right question; "health system factors may be an important overlooked population-level determinant." They suggest that cesarean rates might be most amendable to change through modifying health-care policy. (Lauer JA et al. Determinants of caesarean section rates in developed countries: supply, demand and opportunities for control. World Health Report (2010) Background Paper, 29). 

2. Professionalize:
The 3 original modern professions were the clergy, lawyers, and doctors. Now everyone's trying to professionalize--midwives, doulas, childbirth educators, lactation consultants, and more. She discussed Inuit responses to professionalizing their birth attendants: "licenses are for fishing; why would you want to professionalize midwives?"

3. Pathologize
Pathologizing what used to be normal life events is endemic in our society and particularly affects women.

Next, Betty-Anne discussed three legal cases involving breech births, illustrating how a pathological model of breech adversely effects both parents and birth attendants, regardless of whether there is a bad outcome. I don't have sufficient information about these cases to discuss them here, but I will list the key details and suggest further research if you're interested:

• Alison Osborne vs. the State of California, 1999
• ____ (midwife) vs. Washington State: Sorry, I don't have any more details on the case name or date. It happened at a time when many women were having unassisted births for their breech babies because they could not find any hospitals willing to do breech births. A midwife attended a breech birth and transported for a prolonged 2nd stage; there was no bad outcome. She was put on trial, and the verdict was, interestingly, that "the midwife needs to learn how to do footling breeches before she continues to do home birth breeches.
• Ruth Abigail Light, 2010, Illinois: baby removed from parent's custody because the parents had a breech birth at home.

Conclusion:
Breech presentation carries a higher risk than vertex presentation, but we shouldn't necessarily pathologize it. We should instead approach breech from an informed choice perspective. We need to look at absolute and relative risk. Rather than pathologize the breech, we need to pathologize cesarean sections. We also need to address the undocumented severe mental health disorders stemming from traumatic births and lack of choices.

Marek's response: He's convinced that 70-80% of women don't need a hospital to have their babies safely, while 20% of them do. Our problem is we don't know in advance who will need hospital care. We've constructed our whole maternity care system for those 20%. When he started his residency, perinatal mortality and morbidity were much higher than they are today. Let's not just blame medicine, since it has done a great service in bringing down mortality and morbidity rates.

Our problem is not black and white. Breech is not absolute pathology or absolute normality; it's in the gray zone. Residents need much more skill and experience to learn vaginal breech birth than to learn how to do a cesarean section.We need to re-skill our physicians.

Alternative modalities for turning the breech baby

Marie Julia Guittier: Hypnosis for pain control during ECV
Marie Julia, a midwife & PhD candidate from Switzerland, led a study looking at hypnosis for controlling pain associated with ECV. From an earlier study, they found most women would recommend ECV, but many found the pain to be severe (27%) or excruciating (4%). She and her research partners wanted to know if hypnosis can reduce pain during ECV. They compared 122 standard care women with 63 having hypnosis during the ECV. They didn't observe any statistically significant differences in women's perceptions of pain. Success rates did not improve with the hypnosis group. Physicians had mixed evaluations of hypnosis; most (72%) thought hypnosis facilitated the ECV, although some did not.

Lindsey Vick: Hypnosis to turn breech babies
Lindsey Vick is a hypnotherapist and Reiki practitioner from Virginia. She referred to a study by L.E. Mehl examining using hypnosis to turn breech babies. There were 100 women in the hypnosis group and 100 women in the control group, matched for obstetrical & sociodemographic characteristics. Women in the study were between 37-40 weeks gestation. 81% of breech babies in the hypnosis group turned, vs 48% of comparison group. She started collecting data on women whose breech babies she was encouraging to turn using hypnosis. For more information, see Mehl LE. Hypnosis and conversion of the breech to the vertex presentation. Arch Fam Med. 3.10 (Oct 1994): 881-7.

JoseLo Gutierrez: Moxibustion
JoseLo is an acupuncturist in the DC area. He spoke about moxibustion for turning a breech baby. It can be used on all toes, but the little toe is the most effective. It can also be combined with massage, essential oils, and hypnosis.

Nancy Salgueiro: Chiropractic to prevent & turn breech presentations
Nancy is a prenatal and pediatric chiropractor in Ontario and is Webster's certified. She briefly explained the main approach & goals of chiropractic care: to ensure that the brain is communicating effectively with the body via the nervous system. She then discussed the bio-mechanical connections (ligaments) between the uterus and the pelvis. If there are misalignments in the pelvis, the ligaments will pull on the uterus and not give the baby as much space to grow, develop, and maneuver. Webster's Technique is a chiropractic technique that can be used for anyone. For pregnant women, it's often used for helping a breech baby turn by adjusting the sacrum and by relaxing the round ligaments in the front of the uterus. It involves no direct manipulation on the baby.

She referred to a retrospective study in the Journal of Manipulative and Physiological Therapeutics that found Webster's technique effective in helping breech presentations turn. (I think that this study has a lot of methodological flaws; I'd like to see a better designed prospective study with matched control groups. On the other hand, chiropractic care is unlikely to cause harm, so the only real downfalls of trying Webster's during pregnancy is the cost.)

Nancy recommends starting Webster's as early as 34 weeks to have time to get the pelvis balanced. Don't put it off till the last minute. You can also do this before an ECV to keep the baby from flipping back to breech after it's turned.

Adrienne Caldwell, Massage Therapy
Adrienne is a bodyworker and massage therapist certified to work with pregnant and postpartum women. After her first baby was breech, she started focusing on helping women with malpositioned babies. She agrees with Nancy to start early and ensure you have a balanced, dynamic body.

My thoughts on this session:
Women with breech babies are highly motivated--often desperate--to encourage their babies to turn. I've heard numerous stories of women who tried everything to turn their breech baby: inversions, handstands or flips in a pool, ice packs on the abdomen, music played near the pubic bone, knee-chest positioning, chiropractic, hypnosis, moxibustion, ECV, and more. The evidence for some of these modalities is weak. On the other hand, these techniques are unlikely to cause harm. I'd love to see vaginal breech birth a real option for all women, but in the meantime I'd also like to see more quality research on what really works to turn breech babies. With vaginal breech birth being out of reach of most North American women, turning the breech baby is often the last chance to have a vaginal birth.

Diane Goslin: Breech birth scenarios

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Diane Goslin, who serves a large Amish & Mennonite population in Pennsylvania, described several complicated breech scenarios she has encountered. Gail Tully helped by illustrating the situations with a doll & pelvis. Diane then invited conference participants to share their own less-than-textbook breech births--this included footling and kneeling presentations, slow labors, long second stages, babies that did not rotate to anterior, and nuchal arms.

After learning from Jane Evans the signs of a normal, physiological breech birth, it was very enlightening to learn how to recognize and respond to abnormal breech situations. After all, that's really what breech attendants really need to know. Much of the time, breech babies emerge on their own. But what if they don't? That's when a cool head, skilled hands, and the ability to think on your feet can be lifesaving.

The main things Goslin has learned over the years:

• A lot of patience and a lot of monitoring. A breech is not the kind of birth where you go sleep on the couch. You need enough help in case the mom, dad, or midwives are exhausted.
• Be able to picture your baby well and visualize how it's inside the mother. Become confident and competent with how the baby is positioned inside the pelvis.
• Think outside the box. As much as we might love H&K, for example, we have to be willing to try whatever works to help get the baby out.
• You have to be flexible and see what's working. You can't just have one formula for getting these babies out. We don't like doing manipulations, but it there is trouble, it's better than a brain-damaged or dead baby. You need to know the maneuvers and know when & how to do them.

Jane Evans commented that British midwife Mary Cronk taught her a lesson about getting a stuck object out. Mary had a messy kitchen drawer that would often get stuck because some object was wedged and in the way. Mary's husband would shut the drawer a bit, wiggle the objects around, and then open the drawer easily. The same goes with breech birth. If you can resolve the obstruction, then the baby can descend easily.

Thoughts & reactions

It was an exhausting, exhilarating three days at the 3rd International Breech Conference in D.C., sponsored by the Coalition for Breech Birth. Our schedule was packed from early morning until late in the evening. It's amazing to see the developments since the last breech conference in Ottawa in 2009. 

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

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

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

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

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

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

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

Breech wishlist

After attending the Heads Up! Breech Conference, I came up with a wishlist of things I'd like to see happen:

1) An online, searchable database of breech catchers
This would be tricky to figure out with the illegal/alegal status of some midwives, so we'd have to figure out if we'd only include people who are "out of the closet." I'd like something that a person could search for online by country, then state/province/region, and get info on who will catch breech, where they work, and what they're like (are they hands-on or hands-off, have they done upright breeches, do they do 1st or 2nd twins, primips, etc). Kind of like the VBAC ban database.
The first thing to do is come up with a good domain name, something that's an obvious search term. 

2) A website dedicated to information on breech birth.
There are lots of individual sites out there, but I'd like to have a good, visible website that is THE jumping off place for women seeking information on breech. We'd link to a lot of other sites, but also have our own content (abstracts and full texts of research on breech birth, ECV, and more). First step: obtain a domain name. Any ideas for this?

3) More research on women's experiences of breech birth.
I've actually done the research already but haven't ever written it up. Definitely a project I want to get to in the near future. I have hundreds of responses from women with both surprise & known breeches via a a short-answer and essay-response survey. I'm actively looking for co-authors--preferably with experience coding & analyzing qualitative research; please contact me if you're interested.

4) A comprehensive review of literature on breech birth since 2000.
I was talking with Benna Waites, author of Breech Birth, at the conference (and a few others at the breakfast table, please remind me of who you were!). We discussed the real need for a good review of the literature post-TBT. Benna's book was published in 2001 and I haven't seen anything else like it since since.
1st step: collecting all of the articles.
2nd step: organizing them into a table or spreadsheet. Even having all of the citations, abstracts, and a brief 1- paragraph discussion about methods and applicability would be so helpful.
3rd step: would be to write this up into an article for publication in a medical journal.
This is also something I'd like to be a part of, but it's too much for me to tackle on my own right now. Contact me if you'd like to be part of this project. The first 2 steps could be a collaborative effort, facilitated via shared Google docs.

5) Practical instruction on upright breech birth, written primarily for providers.
This would need to come from providers with extensive experience doing upright breech births (Betty-Anne Daviss, Dr. Louwen & Dr. Reitter, Jane Evans, etc.). I'm envisioning something with lots of practical how-to information and step-by-step illustrations--more of a textbook chapter for physicians and midwives than a consumer's guide. We need a good written resource for teaching upright breech birth, especially something written for providers working in a hospital setting. (OOH midwives have Anne Frye's textbook to turn to. I wonder what updates she might make to her chapter on breech after attending the conference?)

6) And, of course, more breech catchers!
I'd love for every woman to have access to a skilled breech catcher within a 60-90 minute radius. I know I'm just dreaming, but wouldn't it be fantastic if at least one hospital in every larger city had a breech team?

What's on your breech wishlist?

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