Bringing Back Vaginal Breech Birth
Since 2006, a central focus for us has been on bringing back vaginal breech birth. Betty-Anne had attended vaginal breeches internationally prior to doing them at home in the 1980s and at the Riverside Hospital in Ottawa under obstetric supervision in the early 1990s. She now has full breech privileges at the Montfort Hospital, where she attends vaginal breeches as the primary care provider without transfer to obstetrics.
Breech manual with the controversial history of vaginal breech birth, the latest research in upright and hands and knees position, the cardinal movements of the breech based on the Frankfurt and other pioneers in the field of upright breech, and the manoeuvres.
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From Hyper Vigilance of Height and Weight to the Friedman Curse and the Attempt to Bridle the Breech
We are developing a short educational video about the history of surveillance medicine. It explores the history of how medicine started in earnest in the 20th century to study healthy populations as an adjunct to the treatment of those who had already succumbed to sickness. We use the example of the measurement of childrenâs height and weight-- at first of genuine need in poor populations and among the sick, but which became imposed even on healthy well-fed populations. Today the measurement of height and weight is considered an indispensable equation for parents, even though it tells the practitioner little about the genuine health of the child and the parameters developed for caucasians are often imposed on different ethnicities.
In similar fashion, the attempt to define and predict the ânormalâ in labour came into fashion in the 1950s, when Dr. Emanuel Friedman, of Columbia University, published a study that mapped how long 500 Caucasian women at his centre took to dilate during labour. Plotting progress on a chart of dilation within time frames, a rather coercive behavior was adopted by obstetrics to try to get womenâs labours to then conform to this curve. The Friedman curve was based on very interventive obstetrics, including a 55% forceps rate and 13.8% induction and augmentation rate. It was imposed on women for decades even though based on false concepts of "normal."
In answer to the restrictions felt by such interventive obstetrics, women of the counterculture of the 1970s began to have their babies at home. In the early 1990s, following several years of the collection of data of womenâs births, principally at home, via the data from the Midwives Alliance of North American database, we plotted the length of time and the plateaus that women experienced during normal labour. This data demonstrated that most primipara did not follow the Friedman curve. Still it took us several decades to undo the damage caused by overly interventive obstetrics.
By 2014 the American College of Obstetrics and Gynecology arrived at similar conclusion and began to suggest plotting dilation only at 6 cm instead of at 3-4.
More recently, as vaginal breech has been re-emerging and studied in earnest, especially from 2004 on, several practitioners have published or presented descriptions of the cardinal movements of the breech and expectations of what might occur as the breech descends and how to intervene or not intervene (Evans 2012; Frye; Louwen et al. 2017; and Daviss 2017). To date these authors have all refrained from imposing time frames on the progress of the breech, in particular on the descent from ârumpingâ on. Learning lessons from the history of medical surveillance and breech experience in particular, not focussing on timing has been purposeful.
A recent attempt to impose timing (Reitter, Halliday, and Walker 2020) is raising serious concerns among several breech practitioners in the field because of its focus on overly micromanaging the breech and imposing a questionable focus on time instead of on the condition of the mother and the baby. Worse, the time frames in the recent publication are based on a convenience sample of 42 videos taken from the internet and solicitation, with no ability to define the experience of the practitioner attending the births, a full understanding of the interventions used --e.g. oxytocin-- or whether the births were from mothers having their first or 5th baby. Memories of Friedman, which took us decades to undo.
These data are also different from the data of systematic data collections of consecutive births that reveal more ample time allowance for the breech to descend, in particular in the primip (soon to be published). However, we advise not to focus even on these more appropriate timeframes, but on the conditions of the mother and the baby.
Betty-Anne Daviss, RM, MA and Ken Johnson PhD
613 894 2229
Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?
Kenneth C. Johnson
To compare breech outcomes when mothers delivering vaginally are upright, on their back, or planning cesareans.
A retrospective cohort study was undertaken of all women who presented for singleton breech delivery at a center in Frankfurt, Germany, between January 2004 and June 2011.
Of 750 women with term breech delivery, 315 (42.0%) planned and received a cesarean. Of 269 successful vaginal deliveries of neonates, 229 in the upright position were compared with 40 in the dorsal position. Upright deliveries were associated with significantly fewer delivery maneuvers (OR 0.45, 95% CI 0.31â0.68) and neonatal birth injuries (OR 0.08, 95% CI 0.01â0.58), second stages that were 42% shorter on average (1.02 vs 1.77 hours), and nonsignificantly decreased serious perineal lacerations (OR 0.34, 95% CI 0.05â3.99). When upright position was used almost exclusively, the cesarean rate decreased. Serious fetal and neonatal morbidity potentially related to birth mode was low, and similar for upright vaginal deliveries compared with planned cesareans (OR 1.37, 95% CI 0.10â19.11). Three neonates died; all had lethal birth defects. Forceps were never required.
Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position.
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In 2010, we published the study and commentary on the state of vaginal breech in Canada and Europe entitled Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions. View the abstract below
How to Best Study Breech
In May 2015 Lyons et al. published a Canadian registry study in the Journal of the American College of Obstetrics and Gynecology, entitled Delivery of Breech Presentation at Term Gestation in Canada, 2003â2011.
Download the fist two pages of the article (PDF)
Betty-Anne wrote a letter to the journal about it, edited by Savas Menticoglou (co-author of the SOGC guidelines on breech birth) and Andrew Bisits, head of Obstetrics at the Royal Women's Hospital in Sydney, but upon waiting for the feedback from the two obstetricians, the letter to the editor arrived later than the others and the editors did not publish it. Although the Editors suggested that instead, we write a commentary, we were too busy with getting out the Frankfurt article to go back to do so. As we think the letter provides an important perspective.
Download the letter to the editor (PDF)
We have concerns both about Randomized Controlled Trials (see Evolving Evidence Since the Term Breech Trial), and in registry studies for different reasons (see introduction and discussion in "Does breech delivery in an upright position instead of on the back improve outcomes and decrease cesarian section?". We will elaborate on this further in the future.
In 2009, Betty-Anne organised the scientific program for an extremely successful two-day Breech Birth Conference and one-day Breech Birth Workshop in Ottawa in 2009 that attracted over 250 midwives, OBs and mothers. The overallConference was organised by the small but mighty Ottawa-based Coalition for Breech Birth. It really changed Ottawa because it was hard to ignore experts from around the world saying the same thing, "Let's Make Vaginal Breech Birth Available Again," but with a NEW APPROACH.
Then, again with Betty-Anne as the scientific coordinator and the Coalition for Breech Birth, led by Robin Guy, we organised another 2-day breech conference in Washington, D.C. in 2012.
In 2012 we were invited to speak at a breech conference in Sydney and travelled on to Melbourne and Warrnambool on the south coast of Australia, with Frank Louwen and Jane Evans: The world agrees: breech births not the risk they were.
Betty-Anne has done workshops and presentations on breech birth at obstetric units or conferences in Argentina, Australia, China, Czech Republic, Germany, Ireland, the Netherlands, Norway, and in the U.S. (in Denver, New York City, Portland, Oregon, Washington D.C.), and in Canada (in Calgary, Montreal, Ottawa, Toronto, Vancouver, and Winnipeg) and acted as the scientific coordinator for the last two international breech birth conferences in Ottawa, Canada, and Washington, DC. She has also conducted full day workshops at Ryerson University as well as Grand Rounds at Michael Garron Hospital.
Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions.
J Obstet Gynaecol Can. 2010 Mar;32(3):217-24.
Daviss, BA, Johnson, KC, Lalonde A.
Objectives: We wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trialâs two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives.
Methods: In 2006, we sent surveys to the 30 largest maternity centres in Canada asking about their changes in practice in response to results of the initial Term Breech Trial and the subsequent two-year follow-up and the possibility of establishing breech clinics and on-call delivery squads and whether they could include midwives.
Results: Of the 30 surveys sent, responses were received from 20 maternity centres in six provinces. Hospitals were almost five times more likely to adopt a policy of requiring Caesarean section for breech delivery when current evidence suggested that it decreased risk for the neonate than they were to reintroduce the option of vaginal breech delivery when it did not. A breech clinic was considered possible, feasible, and desirable by only one centre, and forming a breech squad was similarly regarded by only two hospitals; 70% of respondents, however, did not entirely dismiss either possibility.
Conclusions: The weight of epidemiologic evidence does not support the practice developed in Canadian hospitals since the Term Breech Trial that recommends delivery by Caesarean section for all breech presentations. Obstetric and midwifery bodies will require creative strategies to make clinical practice consistent with current national and international evidence.
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Newly developed Canadian Guidelines for breech birth from the Society of Obstetricians and Gynaecologist of Canada recommend vaginal breech birth as a preferred option when criteria are met.