North of England Breech Conference II
March 31-April 1, 2017
Frank Louwen and Betty-Anne Daviss: Upright breech: The Evidence from Frankfurt
March 31, 2017
Reviewed by Frank Louwen & Betty-Anne Daviss, April 2017.
Frank Louwen is a Professor of Obstetrics and Perinatology and the Division Chief of Obstetrics and Fetomaternal Medicine at the University of Frankfurt, Germany. He studied at Westfälischen Wilhelms-University Münster from 1983-89.
He has served as Chief of the perinatal Centre (III) at the University Hospital Frankfurt Goethe-University since 2002. He also serves on several executive boards. In 2004 Dr. Louwen started delivering breech babies with the mother in the upright position (on her knees or all-fours).
Betty-Anne Daviss is a registered midwife at the Montfort Hospital, where she has privileges to do breeches without transfer to obstetrics, and the Ottawa Hospital. An Adjunct Professor in Women's Studies at Carleton University, Ottawa, Canada, she has been a midwife for 40 years and is a researcher in both the social sciences and clinical epidemiology. Publications in medical journals have centered on postpartum hemorrhage, home birth, and vaginal breech birth.
Dr. Frank Louwen began by giving some background to his interest in upright breech birth. He attended the last North of England Breech Conference two years ago. He invited Lawrence Impey to the Congress of the German Society of Obstetrics & Gynecology (DGGG--Kongress) next year to give his same lecture.
With breech birth, some people are still comparing apples to pears (i.e., highly standardized cesarean sections versus non-standardized labors and births). Our first task is to understand and improve labor: what is physiological or not? Are we inducing pathology with certain maternal positions?
Maybe breech is physiological; maybe it is a variation of normal. If something happens spontaneously without help, it might be considered normal. In contrast, when a woman is on her back with a head-down baby, you have to do something to help the baby out (deliver the shoulders). Many countries also do various things to "help" the perineum. Thus you might say that cephalic presentation is not normal because you have to "do" things--at least when the mother is on her back. The position of the mother is important.
Frank reminded us that cesareans are related to maternal mortality, childhood asthma (Thavagnanam 2008), type-I diabetes (Cardwell 2008), and the future of the family (see research on cesarean section and stem cell epigenetics by Almgren 2014). Cesareans have an impact on the child, not just on the mother.
Next, Frank gave a brief overview of the Term Breech Trial (Hannah 2000) and subsequent critiques (Glezerman 2005). Even the TBT authors have changed their conclusions in respect to their own data; look at the wording in the Cochrane reviews on breech presentation from 2000, 2001, and 2015:
- 2000: "There is not enough evidence to evaluate the use of a policy of planned caesarean section for breech presentation." (Written while the TBT was underway)
- 2001: "Planned caesarean section greatly reduces both perinatal/neonatal mortality and neonatal morbidity, at the expense of somewhat increased maternal morbidity." (Written soon after the TBT results were published but before the 2-year followup study in 2004)
- 2015: "The benefits need to be weighed against factors such as the mother's preferences for vaginal birth and risks such as future pregnancy complications in the woman's specific healthcare setting....The data from this review cannot be generalized to settings where caesarean section is not readily available, or to methods of breech delivery that differ materially from the clinical delivery protocols used in the trials reviewed....Research on strategies to improve the safety of breech delivery and to further investigate the possible association of caesarean section with infant medical problems is needed."
In Germany, as in many other parts of the world, physicians and midwives have reduced experience with VBB, especially after the TBT. He presented a series of slides showing this trend.
Frank is trying to implement what the 2015 Cochrane review advised: improving the safety of vaginal breech birth. In his own clinic, they had to improve and refine their techniques of upright breech birth. It's a learning process.
Frank also spoke about training colleagues in breech skills: they learn both the traditional on-the-back maneuvers and the hands & knees techniques. Even though they almost never do on-the-back births now, they still teach and practice that skill set. "Don't forget your experiences; improve your experiences," he advised.
She and Frank have a long relationship going back nearly a decade. In 2008 she arrived in Frankfurt, as she was travelling in Europe studying the protocols of the centers still doing vaginal breech births. She phoned up Frank to say that she had found herself in the uncomfortable position of being the Canadian apologist for the Term Breech Trial and he then immediately said, "C'mon over." He showed her some videos of his upright breeches, and she said to him, "This is how I learned to do breeches from midwives in Guatemala 30 years ago!"
As researchers, Betty-Anne and Ken Johnson (the other principal investigator on the Frankfurt study) have noticed that the large registry studies almost always show worse outcomes for VBB than the single center studies. This might be because registry studies include outcomes of all breeches, including undiagnosed births, and births done by practitioners of varying skills.
She briefly touched on three recent registry studies from the Netherlands (Vlemmix 2014), Canada (Lyons 2015), and the US (Gilbert 2003). In the US study, less than 5% of the breeches were born vaginally, which indicates that the attendants were not getting much practice. In the Canadian study, the authors used a composite measure for mortality and morbidity, meaning that both mortality and morbidity were lumped together into one group. From the abstract, VBB seems quite dangerous. However, if you read the full text and separate mortality from morbidity, you will see that the mortality rate in the planned vaginal breech birth group was 0, and the "severe morbidity" was no doubt, as with other breech studies, short-term.
Betty-Anne argued that cohort studies are the best option for studying vaginal breech birth, rather than large registry studies. There's been so much focus on comparing VBB to CS that very little has been published on improving VBB itself. That led to the 2017 Frankfurt study in the International Journal of Obstetrics & Gynecology (IJOG).
She also spoke about how they chose the article's title "Does breech delivery in an upright position isntead of on the back improve outcomes and avoid cesareans?". IJOG initially didn't want them to use a question in the title, but she wanted something accessible to a lay audience and a title that wasn't boring. They had also submitted the manuscript to the ACOG journal. However, The ACOG journal said that they didn't want to obligate American OBs to do VBBs. Instead, they encouraged Betty-Anne and Frank to publish it elsewhere, and then the American OBs could borrow from it at arm's length!
Next, Betty-Anne reviewed the main findings from the Frankfurt study: upright vaginal breech birth leads to a shorter 2nd stage, fewer cesareans, less intervention, fewer maneuvers, and fewer injuries to mother and baby. Although this was a term study, they deliberately put a note about preterm vaginal breeches because so many clinics go straight to cesarean for preterm babies.
On the question of primips: 3/4 of planned cesareans and 2/3 of planned VBBs were for mothers having their first babies. Too often, primps are sent right to cesarean if they have a breech baby, and this study shows that primip breech is a reasonable option. In Ottawa, 80% of the women coming to Betty-Anne for VBB are primips. People only have 1 or 2 babies nowadays, so we will often see primip breeches.
She's glad they had some on-the-back births in Frankfurt in the early days so they had some numbers to compare against upright breech birth. In her unit in Ottawa, she tells the physicians, "If you don't have them on their backs, you don't need to do the maneuvers." Among all of the data of Newcastle , the Frankfurt study, Stuart Fischbein's data, Julia Bodle's data in Sheffield, and Betty-Anne's data in Ottawa, they have not needed to use forceps with upright breech births.
Betty-Anne is now using her hand as forceps in births in the rare occasion where assistance is needed. (See her presentation on Crowning touch at the 2016 Amsterdam Breech Conference for more details.)
What have we learned? Putting women on their backs induces pathology and requires more maneuvers. This is also true in cephalic presentations! In Frank's experience, sometimes he needs to do maneuvers even with upright positions. They're now looking at what influences the rate of shoulder dystocia (nuchal arms) in breech presentations.
The last part of his presentation addressed 3 research papers in progress about vaginal breech birth for VBAC, post-dates, and babies over 3800 grams. He presented these in 2016 at the German Congress (DGGG--Kongress); his group won 3 of the 6 prizes for best research. He urged anyone who wants information or who would like to come train at his clinic to call his secretary Barbara. They have colleagues coming every week from all over the world.
Frank wishes to do an international RCT on upright breech births in experienced units. His plan is to train the units in both positions, as he does with all of the providers at his Frankfurt clinic. Once the units are well-trained and well-experienced, they will then conduct a RCT comparing upright and on-the-back breech birth.
Word is moving about upright breech birth, and we are thinking globally, not just locally. Frank ended by thanking Lawrence Impey for reminding us that we are responsible for what is happening in low-income countries. They look at our papers and adopt our obstetric structures.