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Heads Up! Breech Conference
November 9-11, 2012
Breech birth in American hospitals: Challenges and solutions (panel)
November 10, 2012
Panelists:
- Dr. Dennis Hartung, Hudson WI
- Dr. Martin Gimovsky, New York City
- Dr. Michael Hall, Denver, CO
- Dr. Stuart Fischbein, Los Angeles, CA (Moderator)
Dr. Dennis Hartung works in a small community hospital in Hudson, Wisconsin close to the Twin Cities. He has good support from his hospital and does about 14-15 vaginal breech births per year. He often works with Gail Tully (a.k.a. the Spinning Babies lady) and enjoys doing hands & knees breech births. He accepts women seeking VBB or VBAMC at any point in their pregnancy. Women have come from as far as Chicago, an 8-hour drive, to have him attend their breech birth. Pediatricians tend to be more reluctant to VBB because the babies more frequently come out needing help. None of his 3 OB partners or his CNMs feel comfortable doing VBB, so he doesn't have any backup.
Dr. Martin Gimovsky works in NYC. He argued that Samuel Shem's book The House of God offers some of the best advice for breech birth: keep the collective pulse down. After reviewing the changes in obstetrics between the two World Wars, Dr. Gimovsky commented that maintaining flexion is key in all mammal births. The breech positions we've been discussing today (referring, I think, to upright breech birth) are physiologic. He also defended the appropriate use of technology. Natural processes sometimes are catastrophic. The other extreme is that we don't need meddlesome interference. We need moderation in how we practice.
Obstetrics in the US has always been defined by pediatrics. Doctors like Edmund Piper developed tools to prevent the high perinatal loss common at that time. After WWII, CS became safer. In the 60s and 70s, NICUs came into existence, allowing smaller babies to survive. When he began practicing, patients and doctors trusted each other. This isn't the case today.
He noted how it's important to have the skills to deliver breeches even when doing cesarean sections. At his hospital, they use full-size simulators to teach emergency breech simulations. He also noted the increased risks of multiple cesareans. But unfortunately, many of his faculty don't have training in VBB.
Dr. Fischbein: Is there any chance of VBB being taught well enough so that it could actually come back as a choice in American hospitals?
Dr. Gimovsky: It's very geographic; patient expectation and hospital rules vary by area. He likes the idea of a breech delivery team, like they do with their accreta team. Why has that not taken on in the East Coast? Because of the overwhelming fear that providers have.
Dr. Michael Hall noted that in Colorado, especially in Boulder, women want choices. He's been doing VBB forever. He hopes that a lot of doctors will be pushed back into doing them due to community pressure. If the attitude in this room today could be spread over the country, we'd be seeing a lot of changes come more quickly. His hospital has been good to him.
We're starting to see the complications of multiple cesareans more often, with the increase of accreta, for example. He just met with some ACOG people last week who spoke of the need to bring back these lost vaginal delivery skills. He's confident that breech is coming back (like VBAC has started to). The hospital or his malpractice insurance has not bothered him. He now has begun teaching VBB at the University of Colorado Hospital. The perinatologists are getting excited about VBB. Someone needs to be confident and competent to do it and to teach it. The younger residents want to do it; it's the OBs in their middle years who don't know how and who don't want to offer that choice.
Dr. Fischbein: How do we balance, as OBs, our fiduciary interests (putting patients' interests above our own) and the beneficence-based model of care (having an ethical obligation to support reasonable, evidence-based choices, even if you don't agree with them)? Do you or your colleagues agree with this line of reasoning?
Dr. Hartung: We don't want to coerce our patients into things they don't want. He accepts patients at any point in their gestation who want a breech birth. Once the doulas in his community know something, the word spreads like wildfire. He tries to be respectful of a woman's decision after giving her the information and choices she has. There are people who ignore the information about the reasonable safety of VBB. It's coercion to not allow them these choices. Pediatricians in particular don't seem to understand the concepts of autonomy and a woman's choice, but he thinks it's the right path.
Dr. Gimovsky: The ethics start at the principle of "first do no harm." OBs should refer to other providers if they are unwilling to provide vaginal breech birth. The internet is helpful for spreading information quickly. "The issues about autonomy and safety concern everyone, regardless of where we come from." Consumers need to demand VBB; providers will not do it on their own.
Dr. Hartung: The US healthcare systems' incentives are backwards; providers and especially hospitals make more money from cesareans than from vaginal births.
Dr. Fischbein: Insurance companies could decrease the CS rate overnight if they simply paid twice as much for a vaginal birth as for a CS. Vaginal breech birth requires more time, skill, and experience, so it should be reimbursed at a higher rate.
Susan Roque (an OB from North Carolina) noted that in her area, Medicaid now pays slightly more for a vaginal birth than for a CS. She attends vaginal breech births at her local hospital and recently founded a freestanding birth center, Natural Beginnings, with two CNMs.
Dr. Hall said the same thing is true in his area with Medicaid reimbursement. Midwives now get reimbursed at the same rate as obstetricians. We have to go after the attitudes of the doctors.
Dr. Fischbein: We really need breech centers in the US where women can come from all around, so you can get enough volume to teach future generations.