Aabenraa Upright Breech Seminar

April 2, 2025 Upright Breech Seminar in Aabenraa, Denmark (held at the Sygehus Sønderjylland)

Report written by Rixa Freeze

There were around 50-60 people in attendance, coming from Australia, New Zealand, Belgium Italy, The Netherlands, Denmark, the UK, France, and the USA.

The day started with a lovely video of a spontaneous primip frank breech birth. After this video, Kamilla Groenemeijer Nielsen introduced herself. For many years she worked in Aabenraa, opening the first physiologic breech service that now has an 82% rate of planned vaginal breech births. From there, she has helped many other units in Denmark also support upright breech birth. 

Her goals for the future, besides continuing to educate about and support upright breech birth, are to reach for the "next level": how to achieve fewer interventions in cephalic birth and fewer traumatic birth experiences. Her maternity unit has already achieved remarkably low C-section rates—currently 13.5% overall, and this in a population that is not inherently "low-risk."

Denmark is a country with around 5 million people and 60,000 births annually. It has 20 delivery units in the country with an overall C-section rate of 20%. 95% of healthcare occurs within the public system and all delivery units and obstetricians are publicly funded. This means they can achieve remarkably uniform and coordinated healthcare practices.

Aabenraa, this city where this conference took place and the "birthplace" of upright breech birth in Denmark, sees around 1,500 births per year and, as mentioned previously, a 13.5% C-section rate overall and a 2.5% elective C-section rate. The Aabenraa maternity unit strongly values vaginal birth and women's birth experiences and provides counseling to counteract the fear of childbirth.

At Aabenraa, there is a culture of strong and equal teamwork, where everyone feels safe and supported as they support vaginal breech birth. They review all outcomes together, usually the day after the birth. They value midwives as the experts in normal birth and doctors as the experts in pathological births, working in a non-hierarchical manner to achieve their core outcome, which is vaginal birth.

In Denmark, vaginal breech birth was normal in the 1970s (with a vaginal birth rate of around 74% in that decade). The rate of VBB fell significantly in the 1980s and again in the early 2000s after the publication of the Term Breech Trial. 

However, since the implementation of upright breech birth in Aabenraa in 2014, 14 of the 20 maternity units in Denmark now support upright breech birth, all in a uniform, coordinated fashion thanks to Kamilla's efforts. The exceptions are mainly the large maternity units in Copenhagen.

Today in Aabenraa, 82% of women with breech presentations opt for vaginal birth, with a 50% success rate in labor, leading to an overall vaginal birth rate of 42% among all breech presentations.

Breech birth overview:

Next, Kamilla asked: what are the main concerns about breech birth? In other words, why are we here today holding a seminar? In her mind, the biggest concern by far is avoiding asphyxia and secondarily avoiding brachial plexus injury. Her approach to VBB focuses on avoiding asphyxia and delayed births by diagnosing delays properly and acting promptly, and on facilitating the progression of the birth by using gravity, maternal movement, and positioning. To avoid brachial plexus injuries, they resolve issues by rotating, never pulling.

Evidence update from Shawn Walker:

Midwife/PhD Shawn Walker then gave a data-packed presentation about recent evidence, particularly her work with the OptiBreech study in the UK. Shawn has amassed an impressive number of publications connected to the OptiBreech project, ranging from a RCT of standard vs. dedicated breech clinic care pathways, studies of the role of a breech specialist midwife, to a larger set of data (n=199 planned VBBs) from several different OptiBreech projects.

She spoke too quickly for me to write down all of the research she has done, but here are some points that stood out to me:

They had a finding that was surprising: women in the OptiBreech group who declined ECV had a higher overall rate of vaginal birth than women who accepted ECV first and then went on to have either cephalic or breech births.

The rate of serious adverse NN outcomes within OptiBreech (0.5%) were similar to national averages for planned cephalic births and lower than PREMODA and Barbolla-Foster (1.6%) and the TBT (5.0%). Some of this is of course due to a small sample size, but she anticipates that it would likely not exceed that of PREMODA or Barbolla-Foster.

Maternal movement and position changes during VBB is very important to open and alter the dimensions of different parts of the pelvis. When they are having issues with stuck arms or heads in the pelvic inlet, they particularly like to use the pelvic tuck to open the inlet.

Shawn also gave more insight into why she developed her algorithm, which includes recommendations on timing during expulsion: in the UK, there had been such a "hands off the breech" dogma, even among obstetricians, that it had led to poor outcomes due to attendants keeping their hands off for so long that the baby died or had serious, lifelong injuries. She admitted that more experienced breech practitioners may not need an algorithm and that it was designed for novices who need clear rules due to low experience levels.

Similar to BWB's approach, OptiBreech does not rule out a VBB based on fetal leg position unless there is a true standing breech (nearly impossible in a term baby). They found that nonfrank breeches have somewhat higher rates of maneuvers and of cord prolapse, but not worse NN outcomes. They have adopted the term "dropped foot breech," which Rixa Freeze first introduced into English usage after a Norwegian colleague translated an article for her that mentioned the term.

She emphasized the crucial aspect of allowing the baby to transition with its umbilical cord intact. Breech birth often involves acute cord compression during expulsion, leading to a "shocky" or stunned baby. However, if you let the cord refill after birth, even passively, this helps the baby come around by restoring its blood volume and continuing its oxygenation. In contrast, if you immediately cut and clamp the cord of a shocky baby, it elicits a reflex bradycardia, which causes the baby to crash ad leads to a big (and usually avoidable) resuscitation. She has found the practice of keeping the cord intact very difficult to implement in hospitals, which are generally very strongly embedded in the practice of cutting the cord and removing the baby to the neonatal/pediatric team.

Normal breech mechanisms (Kamilla)

Using several breech videos, Kamilla reviewed the mechanisms of normal breech birth. In her approach, the goal is to have the baby born within 5 minutes of the "white line" or birth of the bitrochanteric diameter (what we at BWB call "rumping," but should be distinguished from how Shawn Walker and OptiBreech define "rumping"). This is the point of no return at which you are fully committed to a vaginal birth.

(In this conference report, I use "rumping" to mean the birth of the bitrochanteric diameter, as used in BWB teaching materials.)

Basic principles of VBB at Aabenraa:

1. Always have an experienced team present
2. Always place a fetal electrode (also called a "scalp clip") at the onset of pushing to ensure the baby has good resources prior to rumping. They find that the electrode picks up on the FHR much better than external monitors. Once they reach the white line/rumping, they expect it will take no more than 5 minutes and they have the woman push without waiting for contractions.
3. They encourage upright positions and maternal movement during labor and especially pushing
4. They follow a flowchart (a simplified version of Shawn Walker's algorithm) and they always diagnose an issue BEFORE moving to any hands-on actions.

Abnormal breech

Kamilla empathizes and trains for four main complications, which are in her algorithm

1. Uncomplicated arms (when an arm is raised/stuck but can be reached and swept down easily, usually associated with oblique positioning) à resolved with arm sweeps
2. Complicated arms (anterior arm stuck on the pubic bone, may be nuchal/raised, baby remains completely sacrum transverse and arm cannot be swept down) à resolved with a rotational maneuver (Front to Back or "Face to Pubes" is her preferred maneuver)
3. Head stuck in the pelvic inlet: this is very rare and involves bone-on-bone impact, where there is a hyperextended head stuck in the inlet. No amount of flexion or forceps will resolve this issue; it requires disimpaction/elevation, rotating the head to the oblique, and then helping the head drop into the pelvis
4. Head stuck in the pelvic outlet: this is the most common situation and resolved with the usual head flexion maneuvers, usually a shoulder press or Crowning Touch/scoop and flex

[lunch break and optional tours of their labor rooms]

Rixa's note: I was able to have a quick tour from one of the midwives, joined by Nick Rubashkin from UCSF. They have 6 large labor rooms equipped with deep tubs, delivery beds, bedside resuscitation tables, and larger double beds generally used laboring or postpartum. Each room also had a very large ensuite bathroom, including a shower. Some of the walls behind the tubs had large murals; others had huge screens that could play nature scenery.

Afternoon activities:

We broke into 3 groups rotating through 3 different activities:

1. Case presentations (usually videos) and discussion led by various practitioners

2. VBB videos from Aabenraa plus discussion

3. Hands-on practice will doll & pelvis and simulators (using cards presenting the 4 situations in Kamilla's flowchart: uncomplicated & complicated arms, head in pelvic inlet, head in pelvic outlet)

Rixa's reflections: After seeing many VBB videos from Aabenraa, I noticed that they use gluteal lift frequently throughout the entire expulsion, not just to help at the very end with the head. While it can increase visibility, I question how much it facilitates progress while pushing out the rump or the legs or the arms. I also wonder if having hands pushing on the mother's buttocks may inhibit her spontaneous movements, because her pelvis is being held immobile. It's not an invasive or painful intervention, but it's still an intervention that may affect the mother's ability to move freely. This is not intended as a criticism but more as a reflective question.

After a mid-afternoon break, we all gathered back together to learn from Andrew Bisits. He gave an abbreviated demonstration of how he counsels with couples prenatally. He asked me and Nick to play the role of "expectant parents" while he counseled us and responded to our questions. One really important thing Andrew has learned is to never start this type of conversation by talking about risks or poor outcomes. Instead, he always starts by explaining how both vaginal breech birth and breech cesarean section work. Then he reviews the maneuvers that may be used during a VBB or a C-section to help the baby be born. Finally, he goes over the short- and long-term risks and outcomes for both mother and baby.

Kamilla: CTG during VBB

Kamilla then presented about how she uses and interprets CTG during vaginal breech births. She uses STAN along with physiological interpretation of CTG; as a result, she doesn't need to look at lactates or pH anymore. She uses a scalp (buttock) electrode in all vaginal breech births, placed at or before the onset of pushing. Before that, women are on wireless monitoring.

She showed several birth videos alongside their CTG strips to illustrate that significant bradycardias or other pathological tracing can occur at the very end and the importance of prompt action to avoid adverse outcomes. Babies can deteriorate very quickly during a VBB and it's important to be listening closely and act quickly if this happens. If the baby is close to rumping, you can try to get it to rumping quickly (she uses maternal pushing, movement, gluteal lifts, and then, if necessary, episiotomy).

Rixa's reflections: I'm hesitant about the use of episiotomy rather than fundal pressure if the birth needs to be expedited; I like the idea of power from above rather than cutting from below. But Denmark is a country that does not use fundal pressure much, so they are understandably slower to adopt it than other EU countries where it is used more frequently. Our own BWB clinicians have used episiotomy rarely if ever (1 in over 500 births for Kristine, none in all of Dr. Hayes' breech births.)

She also touched on breech-first twins, which the unit has done a few times, although that is quite rare in Denmark.

Finally, she concluded with several slides about the implementation process in Aabenraa and the subsequent maternity units that have followed her program. They started first by training a small core team of doctors and midwives, then expanded by training the essential staff and finally ended by having all staff trained. There is always an upright breech specialist on-call if not on-site. I love that they video all of their births and review the videos with the entire on-site staff the very next day, always in a spirit of learning rather than of blame. This practice avoids the rumor mills and blame game that can happen after a difficult birth or poor outcome.