Thursday, August 25, 2016

40 weeks, lots of fluid, baby not engaged

Congratulations on your baby, beautiful Mama!

You've made it to 40 weeks and have much reason to be proud!
But you're doctor has expressed a concern that the baby's head is not yet in the pelvis.

Julie checks to see if her baby's head is in the pelvis and finds that is not.

This baby is engaged and then some. 0 station, shown here where the  "0" sits between two arrows, shows the middle of the pelvis. When the top of baby gets to "0" Station, the baby is considered "fully engaged."

Forehead over public bone. 

Some phrases for a full term baby that hasn't moved down into the pelvis are, 
  • Still high 
  • Floating 
  • Not engaged
  • Unengaged
  • And, sometimes I talk about the head that is "overlapping" the pubic bone
  • This last is often because baby's forehead extends beyond the pubic bone (occiput posterior)


Readers,
this is an answer to an email. Read on for the personal experience: 


You've mention that the doctor thinks your baby may not be engaged because of the amount of fluid. Additional reasons (above) a baby is not engaged due to fetal position,
soft tissue issues or pelvic alignment, or a more unusual reason of size.
Checking for the baby's head. Is it deeper than the pubic bone or does it overlap?
The engaged head is deep inside and can be hard for a mother to find.
The unengaged head of a posterior baby will overlap the pubic bone.



I am guessing this is your first baby since you didn't mention another pregnancy.
When I was a practicing midwife, I noticed that many first pregnancies often begin labor at 41 weeks and 2 days. Expecting baby to come at 40 weeks is all very round and tidy, but not particularly likely.

To prepare for a good chance of you starting labor on your own about 41 weeks and 1 day to 41 and an half weeks, having a pelvic alignment session with a myofascial body worker and chiropractor is a reassuring idea. 

If cesarean is an option for you, then timing becomes a variable. It is too easy to slide into a decision that once you accept a cesarean to get things over with. Rather, hold that thought for the appropriate time. My personal opinion, based on Dr. Michel Odent's descriptions in his book, Cesarean, is that if a cesarean is needed to do it after labor begins on its own.
But it is approximately 50% likely that if you begin labor with baby still high that labor will bring baby lower. There are several studies showing that statistic. I've found some easy-to-do techniques 
helps baby get lower into the pelvis. Many women find these help labor to speed up but also EASE up! A fantastic combination!

 Spinning Babies Quick Reference download teaches you what to do to if baby stays high, but I'll give you a quick version of the quick version here:


Adding balance, alignment, and mobility now will help success for you once contractions begin.
After contractions begin and are predictably regular and coming 4-5 minutes apart, doing ten Abdominal lift and tucks will often engage baby's head in the pelvis. It's important to open the top of the pelvis when lifting the belly. See the instructions. Do ten in a row the best you can. These don't work unless you are having a contraction!

When finished with that you should feel pressure on the cervix and not on the back (or less so on the back as before).
Only after trying that and waiting an hour or two to see how labor goes (if given that time in the situation) then try Walcher's Open the Brim

Sometimes, though there is a bit of a risk of malposition from breaking the bag of waters. In 30 years, I have not found it necessary at the low-risk, normal births I attended. 

For women with truly high levels of amniotic fluid, doing a slow leak release of the waters brings baby down. Preceding this intervention with balance first may help the mother's muscles be softer and more symmetrical for baby to drop lower in the pelvis. The resistance of shortened or unconsciously held muscles will reduce.  

I notice a cesarean is less likely if the epidural or the rupture of membranes is done after 5 cm dilation. The data collection on that is not great. But it is clear in the studies that epidural is associated with more posterior babies than no epidural. If an epidural is planned, timing it after active labor has rotated baby to occiput anterior may offer the best chance at vaginal birth. It's not an either or issue, but there is an issue with how babies rotate after some epidurals. You take a chance. 

Getting baby on the cervix with the above plan will help baby onto the cervix and then dilation will be steady as long as rotation is equally easy for baby. 

Nature will engage most babies. Supporting nature means reducing the effects of living in gravity. It's not about right or wrong. It's more about having experienced a number of events or a single key event while living in gravity! A sudden stop during a twist or a previous sprained ankle are two such events that SOMETIMES effects pelvic alignment and thereby baby's path through the pelvis.

Again, balance makes rotation easier for baby
Rotation makes engagement more successful. 

It is quite likely labor will begin spontaneously
When labor starts about half of babies come into the pelvis with no other action needed.  Baby will come down with engagement. It is also fairly likely that doing these activities will help a slow labor or a labor that hurts more than one with which you can cope. (Mindfulness, breathing, and relaxation techniques are excellent.)  Adding balance means helping release what is tight or twisted or support what is loose. Often supporting what is loose is done by releasing some muscle or ligament across the body from the loose area. 

Beginning labor has many benefits
Preparing baby for breathing air is one benefit. Awakening areas of the mind to maternal intuition is reportabley another. Knowing your body can start labor has a satisfaction in itself that is missed by some women who never get the chance. 

Decision Time
Whatever you and your doctor decide, whatever course you choose, you can aid your chance of a vaginal birth by activities before and during childbirth to make room for your baby. Easier birth for babies means easier birth for you.



Sunday, August 21, 2016

The New Face of America's Breech Experts

Many hospital systems have taken to denying their doctors give vaginal breech birth care for families carrying breech babies. These are physicians who've devoted their lives to giving excellent obstetrical care. I believe they have a right to provide that care. I believe midwives who obtain the added expertise also have the right to provide breech birth care. Each caring for the communities of women who choose them to do so.

Today I met with Leslie, Jason, and their two children. They are a family for whom I kept watch while they gave birth to their second breech baby and second home birth. Their midwives invited me to come along for the added security to the safety of the birth that my experience would bring. Without the supportive midwives, Leslie would have had a high chance of being cut open against her will.

On Friday, Sept. 23rd, Leslie will talk on the Breech Panel at the Spinning Babies 2016 World Confluence about their surprise breech followed 3 years later with a planned home breech birth.

In the previous blog posting I talked about skilled doctors loosing their right to attend to breech birthing families because their medical institutions administrative decisions. Likely the fear of legal costs was cited but peer pressure is at the root. The majority of doctors won't assist breech births because its more controllable and less skill to do a cesarean. You can train surgical skills more readily than the complexity of breech birth.


There are few doctors left who offer breech care in this country. Most, like Dr. Brad Bootstaylor, above, have been forced to stop at their hospitals make policies against breech birth.

Midwives, like those in California, are also being denied the right to practice their profession fully. Some midwives taking policy roles are giving up the right of breech birth for their sister midwives. They themselves are not interested in attending breech births. The status of breech skill teaching is extremely poor in general in this country. Therefore, without real understanding, breech birth can be scary to the providers. The risks increase when skills decrease.

So who is left to care for families, women and babies who like to keep their heads up? Drum roll, please...

I'd like to introduce you to the new American Breech Expert:  The first responder. Fireman, paramedic, police, even a taxi driver now has as much chance of catching a breech baby as the average obstetrician.


This South Carolina Firefighter, with less exposure to breech birth than a midwifery student, is the new face of Breech Competency. He did what he had to do to serve this baby and her family - and likely on a half-a-day's worth of childbirth training. With or without high level skills, what care this firefighter could muster is denied everyday to highly trained doctors and midwives of our nation.

America squanders the skills of the few remaining maternity care experts in breech. Canada has their experts teaching the next generation of maternity care providers, in case you were wondering what else our wise elders might be doing.  Policy and politics may intend to leave the catching of breech babies to the men and women who won't challenge the justification of the OR. No medical system expects all babies born in the hands of paramedics to actually live. They are out in the wilderness, so to speak, facing the unfathomable. They will not be found wanting, for they are willing to show up.

These American Heroes do not shirk their responsibilities but rather face them without the full training that would be achieved by a doctor or midwife if it were not denied to them, perhaps even at the very hospital where the firefighter brings in the mother and newborn from an unplanned out-of-hospital birth.

Be assured, the course of modern maternity will not divert from finding the highest cesarean rate sustainable up to the point where maternal mortality upsets the membership. Oh, did you think I meant to say, up to the point where the maternal mortality rate begins to rise?

No, that rate is between 10-15% cesareans, according to the World Health Organization. Whereas, our society accepts a 34% rate. Some would like it lower, and even our Public Health officials cringe at our current rate knowing women are dying to reduce litigation for the obstetrical profession, for courts still think that if a cesarean was done the best care possible was given.

Physiological breech birth is the best care for over half of women with breech positioned babies. Our nation has to catch up and learn the possibilities of gentle breech birth.



Banning Breech in Atlanta

Dr. Brad Bootstaylor of SeeBaby.org in Atlanta, GA is someone I highly admire. He is a leader in the Atlanta birth movement. I've been to his office, he blew my mind.    He  was unethically restricted from providing care to birthing women having natural childbirth for their breech babies.



"Dr. B" has the skills, he has the intent, and the community of birthing families choose him. This is reason enough for the medical policy makers to shut him down.
This means that yet another bearer of the treasury of birth skills has been denied his God-given and self-determined path to the skills necessary for the preservation of the Human Right of birth for those coming bottom first. Here is the notice:

To our amazement and disappointment, See Baby Midwifery was advised by DeKalb Medical on 8/17/16 (yesterday) that we can no longer support birth options for mothers to include VBAC, water birth and vaginal breech deliveries.
This sudden and unexpected lack of support brings great concern to us and our community.
Temporarily, all VBAC eligible patients will be birthing at Emory Midtown with Brad Bootstaylor, MD.
http://seebaby.org/see-baby-midwifery-dekalb-medical/


Hospitals around the nation short-sightedly make the same Human Rights violation. In my area, Dr. Denny Hartung was blocked and in Los Angles, Dr. Ronald Wu faces the same.

September 7th there will be a Demonstration on Wednesday, Sept. 7th at 11 am, at Glendale Adventist Medical Center. 

The FaceBook event page says,
Last week, Glendale Adventist Medical Center created a policy outright banning vaginal breech birth...

GAMC is fortunate to have one of the most skilled breech practitioners in the country. Dr. Wu is an honored physician who has assisted women with vaginal breech birth for more than 40 years. And while this policy appears to affect the entire obstetric department, the reality is, it’s directed at this one specific provider, making it seem punitive and unnecessary.

We are concerned that this change seems to be motivated by political and perceived financial concerns instead of what is in the best interest of mothers and babies.

This is a policy that forces women into cesarean sections without respect to patient autonomy in decision-making and their legal right to informed consent and refusal.

We believe there is much evidence to support VBB that was not considered by those involved in this decision. Basing a policy on flawed information and perceived but not actual liability is an erroneous precedent.

A couple of people have spoken to the hospitals CEO about this matter without resolve. ImprovingBirth, in collaboration with a group of Los Angeles area providers and a couple of their celebrity clients have sent a letter to their board of directors requesting a meeting which we are less than confident will actually happen.

We will rally to bring awareness to this unethical policy and we hope you will join us.


Next blog post, I'll introduce the new US Breech Expert carrying this responsibility denied to Dr.s Wu and Bootstaylor. 

Monday, August 1, 2016

Face Presentation

Some of us like to face the music, face the facts, turn to the light, face life full on...
The baby who is coming face first, or face presentation, most often is born fine in this position.
There may be a little slow down after ten centimeters which can be helped by standing in a shower, moving and swaying, each a variation for comfort while standing through contractions.

From book of Smellie, 1800s

Face presentation is not the same as posterior presentation. But a face presentation can be occiput posterior with the chin anterior.
You may see more face presentations among premature babies, large babies, babies without skull development (anencephaly) or in women with small pelvis and large baby. Abundant amniotic fluid may allow for a face presentation, and those are the medical list. I would add that a twist in the lower uterine segment such as may also make a posterior or even a breech baby more likely may alternatively lead to face presentation.  A fall or jolt during or long before pregnancy may be examples of events that can cause such a twist. 
Face presentations occur from about 1/500–to 1/1,250 term births depending on who you ask. Duff and Benedetti wrote about face presentations in the 1980s.

The chin is the landmark of the face presentation, unlike a flexed baby whose occiput is the landmark.
  • Left Mento-Anterior (LMA), Left Mento-Posterior (LMP), Left Mento-Transverse (LMT);
  • Right Mento-Anterior (RMA), Right Mento-Posterior (RMP), Right Mento-Transverse (RMT)
Baby's whose chins are posterior are aiming their chin over the perineum. If contractions are slowing then there may not be the strength of momentum to bring the baby through the perineum since the chin is not sweeping the perineum open. There isn't enough pressure. The back of baby's head may not be fitting through the pubic arch on the front side. 

I was at one birth like this. The chin was on the perineum and 5 contractions didn't move baby forward and the little face was quite red and swollen. During this time, the mother tried squatting, hands and knees, and pushing on her back. (She squatted on the OR table in the hospital with 8 staff ready for a cesarean.) near and an episiotomy was necessary and then baby literally fell out. It was the first episiotomy I had seen. The cesarean was avoided and the baby born. The mother would not have needed an episiotomy with a flexed head. This was her first baby, and baby weighed 8 and 1/2 pounds, or a bit more than 4000 grams.

This position is considered impossible in the text books. All things vary, and some babies do and some babies don't follow the text book. 

What to do about a face presentation.




Some midwives have told me that in labor, 
they have inverted the mother just as in a forward-leaning inversion and then
shook her buttocks with their hands or using a rebozo. I call this a tootsie roll wrap and find it jiggles the buttocks quite well. This both relaxes the mother's deep muscles after a few minutes, and works baby back out of the pelvis. The oncoming contractions help keep baby head down. 

I am not sure that this would be wise in pregnancy without contractions!
Women can not invert if they have high blood pressure. 

Helping women into a parasympathetic state, or a more deeply relaxed state can help, and jiggling accomplishes this as well as other body work techniques. 

Balance is the key. The baby is not likely to be in this position if the surrounding supportive tissues are symmetrical. There are many roads to Balance. Balance the mother and the baby may flex. 



FYI, F. L. I. is Knee high

How high the couch? Inverting safely


Anisa asked, "Can anyone guide me about Forward-leaning inversion? What should be the height of the couch from which we are going to lean downwards."


The answer is within...
Or, rather on you? It's the height of your knee. Since women come in different heights, I'd suggest you see if your couch or bed is about the level of your knee.

The height of the couch approximately matches the height of the knee of the person who will invert.

A couch slightly higher than the knee is fine for a fit mother.
A lower surface may be better for someone with weak shoulders or more weight than average.

The steps to the forward-leaning inversion are at Spinning Babies website.
Don't invert if you have high blood pressure or other risks of stroke.
http://spinningbabies.com/learn-more/techniques/the-fantastic-four/forward-leaning-inversion/

Tuck the chin and don't lean on your head.
This helps the connective tissue have room to "unwind".

Tuesday, July 5, 2016

Teach the Breech Review of Day 2


Day 2 of Teach the Breech was just as exciting as Day 1


Dr. Anke Reitter shared her new pelvic measurement research which she brings to us in September in St. Paul, MN. Where is the pelvis larger when moms crouch?



Several stations with manikins and dolls allowed for hands on practice.




Dutch  Midwife Rebekka Visser spoke on the lack of a control group for breech birth.


 UK midwife Shawn Walker gave a brilliant talk on collaboration. She started with a humorous anecdote showing a brilliant insight to the culture of birth care. Her talk as well as her tweets are comprehensive, insightful and academically satisfying. 



Betty-Anne Daviss and Ken Johnson spoke on the statistics and dynamics of research. These two crossed the ocean of differences between OB and midwifery breech care to increase safety in both by doing the data crunching for the Frankfurt breech research.  This study, I believe, is the key to safe breech birth on earth. This is where we go to open the birthing rooms to breech birthing families in hospitals and increase the safety of midwifery-led breech care in all settings.

What amount of training makes breech safer? 


Frank Louwen  teaches obstetricians from his University medical center as well as occasionalHe  visiting obstetricians from around the world. He says we must have better training and better methods  for breech birth that isn't dangerous. After showing us the upright breech birth statistics, he actually said, "Breech birth isn't dangerous."  It is more complicated than cephalic but statistically very justifiable.




Dr. Louwen points out that a provider is not competent until they can identify when breech is not progressing normally and have the solutions to return the baby to the position of progress. 

Dr. Louwen identified how to see when the breech baby was stuck and several safe, and simple ways to handle various complications of breech births. I've been using the identifiers and techniques he teaches and can say without a doubt that his teaching has saved half a dozen lives while making another half dozen more comfortable (figuring someone would have figured those easier degrees of obstruction out). This is information that North American midwives do not get in their training or traditions! It must be shared and understood to make breech practice approach a level of safety to safely offer labor care for selected women. 

Teach the Breech Review of Day 1


The Netherland's.... for decades the natural birth
hub which, for the world,  equated best practice with Holland. But today Dutch homebirth rates are less than 1 in 5, and the right to breech vaginal birth is threatened to follow the rest of the world's unthoughtful trend to extinction. 


Countries rush to follow the campaign to eliminate vaginal breech birth in favor of surgical birth of the breechling. The US is systematically involuting hand skills for technological dependency and so accepting a rising subsequent maternal death rate just as a politician postpones ecological enforcement and other high tax projects, like bridge replacement.  The US breech BIRTH rate is less than 3%, and the 97% breech cesarean rate is only as high as these fast little birthlings can be detected. These few just surprise us before surgery can begin. 

How are US Obstetricians to know normal breech when A.) Breech statistics reflect premature and poorly prepared providers and teams in their outcomes, and B.) The Term Breech Trial was conducted by centers that did not have already successful breech birth clinics. Experienced breech centers would not participate in a random control trial because it is a dangerous proposition for vaginal breech birth (Kotaska). 

To hold on to the Dutch quality of service, 50 Obstetricians joined nearly 200 Midwives from The Netherlands and around the world to affirm the value of achieving better breech skills. Even the phrase, "better vaginal breech skills" denotes a purpose subdued for some 45 years  - since the surge in cesarean sections made breech skills a lesson of medical history!




Teach the Breech Conference ignited an Amsterdam harbour warehouse with the contagious enthusiasm of the world's core breech experts. Their skill and confidence drew in highly skilled providers who understand the need to preserve knowledge about the 3-5% of births in which babies come pelvis first before their heads. 


Dr. Joris van der Poste, MD, PhD, Professor of Obstetrics and Gynecology at Academic Medical Centre, Amsterdam; Fedde Scheele, MD, PhD, Gynaecologist of Onze Lieve Vrouwe Gasthuis, Amsterdam; and Ruth Evers, Midwives and Senior Trainer at Talmor, Amsterdam devised the conference and ran it with smooth professionalism. 

First on the stage was Dr. Frank Louwen, MD PhD, Gynaecologist at Universitatsklinickum, Frankfurt, Germany. There was a warm revelation of his family name being Dutch and pronounced much softer (loo-in, almost like loon) than in Germany (Lo-Ven), both quite different than the American mispronunciation, (Lou-When). He gave a rousing "Origin Story" of how his brain saw again a diagram of a breech delivery process called the Bracht Maneuver from upside down when to talk on the phone he circled his desk and glanced back at the open book from above the drawing. Revelation struck!

If the mother were on her hands and knees, the doctor wouldn't have to grip and pry the baby out! He knew handling the baby was the greatest risk to the baby. By the new view of breech, he suddenly had a solution to avoid the greatest risk to breech birth.

 In their study, no mothers died and only babies with lethal anomalies. The rate of interventions for hands and knees breech birth was lower than 1 in 5 compared to over 90% for breech birth on a woman's back.

Labors began when babies were term, frank or complete but not footling, clinical pelvimetry was normal or larger, and the mother desired vaginal breech birth. Labors were stopped and a cesarean was done if the baby didn't come down, if active labor stopped, or babies vitals were not good.

The anterior buttocks are born.
Upright breech 2nd stage was significantly shorter, with less perineal injury and remarkedly, Apgars less than 4 were only 3.1% compared to 10% with women on their back.

It's a paradigm shift. America is behind the times. Our question here, Is breech birth with an American Obstetrician or midwife more dangerous than cesarean breech delivery? Until we adapt the training of those obstetricians who conducted the PROMODA study approach to conventional breech birth or perhaps, better, the upright breech birth as in the "Frankfurt School" (not a building, but a method), then we shall not have a happy answer.    
Meanwhile, midwives have been attending breech and cephalic (head down) births in this way for millennia.  Betty-Anne Daviss, RM, MA, Adjunct Professor and Registered Midwife at Carleton University, Ottawa, Canada gave her story of origin in how she learned about all-fours birth solutions from Guatemalan midwives in the 1970s.

Breech teaching skill- keep my hands out of the way and
still hold the pelvis steady!


Betty-Anne Daviss introduced the "Crowning Touch" single handed flexion of the stuck breech head. The audience was extremely moved by Betty-Anne's ingenious innovation.


After coffee, three Dutch obstetricians spoke on improving External Cephalic Version and the statistics. I missed any mention of risk, but that may have been because the topic sets me to replaying a horrific phone call following up a US breech mother who told me her baby passed away after a successful ECV - only to be told it was a tragic coincidence. It's a topic that I approach with caution to the point of cotton in my ears.


Favorable characteristics to successful breech flipping through ECV.
Dr.s Marjolein Kok, Joost Velzel and Midwife Mary Sheridan shared their effective success with manually turning breeches in both Amsterdam and London.

Eternal Cephalic Version, or ECV.

Yet, they also told the follow up statistics of what happens when the baby is manually turned. A higher rate of cesarean follows compared to other head down babies.




Not always favorable outcomes.
If you follow me on Spinning Babies, or have taken the workshop, you will know I believe that as many as 80% of breeches are breech for a reason of a misalignment of maternal anatomy "balance." This number could be lower, but it's a hefty percent. When we see the highest level of bodywork we see many of the breechings flipping spontaneously. That's my goal. I do hear from providers that when the mother puts the body balancing routine of the 3 Sisters and professional body work into the week preceding the ECV that either the ECV is no longer necessary or is easier than comparative ECVs. We need study on that, of course, but the anecdotal response is from multiple continents and practices.

Some of these cesareans may have been avoided if vaginal breech birth was supported with skilled providers. But many cesareans are avoided on the other hand. Options for what to do are necessary and needed to meet the needs of families and providers in all their variations.

These highly skilled practitioners were received with high regard for their compassionate and vital work. It's inspiring to be in the European academic community and see the high level of collaboration. This conference was a glowing example.


This picture is an hour before start.
I wish I could have shown you lunch!!








After lunch, this middle American middle-aged midwife presented a couple particularly perplexing breech births that became complicated and required on-the-spot innovation of technique. We can learn a formula for breech complication and we must. I highly recommend following the all-fours formula until you have resolved several cases of trapped arms and head. Then you will have in your hands a knowing that allows you to free the stuck breechling in other positions the mother may take. 

I don't believe we as providers should always follow the mother's choice. This is a provocative statement at first, but just explore for a moment what this can mean. In the water pool, the mother can not respond to the baby's head sliding past her pubic bone and clitoral ligament (get why she may move suddenly?) there in the same outlet opening way she can do when free movement is available on her living room floor or a firm hospital bed.  So she remains in an inlet closed position when on all-fours in the tub and you must improvise or get her out of the tub, the baby hanging by the atlas. In one video, I showed how I, similar to Betty-Anne, rotated the baby's head with my finger tips on the temporal bone when the mother remained in the birth tub in such a position that the baby floated out of flexion and lost vitality due to a delay in the birth. I brought the point around to that once you understand the principles and the three levels of the pelvis you can improvise. Then I showed my solution for freeing a small first twin's arm from the symphysis with an external maneuver which I will present in detail this September. 


Follow the formula until the inside of the woman's pelvis and every potential for the stuck breaching is as clear to you as "reaching into your sock drawer at midnight" and you will then be a safer provider when the unexpected happens in less accommodating maternal positions. Meanwhile the esteemed, highly trained professionals seemed a bit shocked and dismayed by the novice in the field. Yet, I showed this for exactly that point, that in North America there is little breech skill and with my small numbers, I am still one of but a handful of the most skilled breech providers in a 500-mile square radius.  I may proceed with duck tape and a prayer, but women have the right and will exercise their rights to vaginal breech birth with or without a skilled provider. One of the reasons is ideology and naiveté, if breech is normal, then why would one need a skilled breech provider? Normal means easy, doesn't it? 

After my own presentation it was lovely to hear Frank Louwen's admonishment that breech is not dangerous. Know the pathology and solve it as it may appear. Then you have the  level of safety that can restore breech skills to the world. But that talk was on Day 2, so wait for it.

Irene De Graaf, MD, PhD, Obstetrician at Academic Medical Centre, Amsterdam creatively and humbly collaborated with famous Midwife, Rebekka Visser, Midwifery Practice Springtij, Usquert, in the north of Holland. 


Several Dutch obstetricians spoke with a freshness revealing their personal renewal to considering vaginal breech birth as a potential worth protecting and exploring.

Floorjte Vlemmix, MD, PhD, Resident O & G at Academic Meidcal Cnetre Amsterdam; Lester Befgenhenegouwen MD, PhD Gynaecologist at ZGT Hospitals, Almelo and Hengelo, The Netherlands; and perhaps my favorite presentation was given by Thomas van den Akker, MD, PhD, Resident O&G at University Medical Centre, Leiden, The Netherlands. He spoke of the widespread consequence of high resource countries promoting cesarean breech delivery on the maternal and infant death rates in low resource countries when they are not supported in vaginal breech birth and must switch to cesarean surgery in unfavorable conditions.

One slide revealed the rate of future siblings lost to save the first child. Dr. van den Akker shows that for every 10,000 cesareans done for breech position, 26 babies lives will be saved - but in subsequent pregnancies, 27 babies will die from complications relating back to that first cesarean.
Dr. Thomas worked in Malawi, a low resource country, which copies US obstetric protocol of doing cesareans for all breeches, yet in Malawi's compromised conditions. Another slide showed how many of their mothers die from cesarean in high and low resource countries. In Malawi, 6 women die per thousand cesareans done for breech.  Remember, these are comparing cesarean to breech birth on the back, which is not as safe for the child as when the mother is on all-fours and the cord is not cut.

 Having served an American middle class family who lost a mother to cesarean complications, the reality of his data is poignant in my mind.

Like the promotion of bottle feeding where clean water is not available, promoting surgery where electricity and hygiene, blood replacement and medications are scarce is assigning a death sentence to be like the American Jones, but also because the obstetricians with status can't even speak to breech skills for the, in this case, Malawi obstetricians for whom they are mentoring.

The horrendous effects of the ego in medicine are life threatening in as much as they innovate. So how to proceed? The process of the ego in accepting all-fours breech birth is diagramed by Irene De Graaft in the slide above: "No, Never! Impossible!"  to "I don't see any advantages; why is it better?" to "How can I learn/get enough experience?"  to awakening with a question, "What if...?"

An expert panel here moderated by the unflappable Ruth Evers modeled the route to better birth practice for breechlings and their welcoming families and providers. More soon, but now I must get the newsletter out!  



Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.