Heads Up! Breech Conference

Selection of candidates: Factors to consider (panel)

November 10, 2012

Panelists

• Andrew Bisits (Australia)
• Martin Gimovsky (USA)
• Jane Evans (UK)
• Sophie Alexander (Belgium)
• Marek Glezerman (Israel)

The panelists answered the question: What are your criteria for a vaginal breech birth?

Andrew Bisits prefers a woman who is informed, along with her partner, and is motivated. He looks for a good level of understanding and cooperation. He always feels better about the situation if there's continuity of midwifery care.

• EFW <4000g
• Baby not growth-restricted
• Presentation of baby prior to labor doesn't bother him. He looks at presentation at the onset of labor; he will advise CS for footling at onset (but he doesn't always do a CS in this situation).
• Labor progress: once the woman is in established labor, she should progress roughly ½ cm per hour. You're not necessarily watching the clock; these are just overall guidelines.
• Pushing stage: if the baby is not descending after an hour, he will start asking himself questions. After 2 hours, he will definitely advise a CS.
• Does not exclude primips.

He uses ultrasound to assess the baby's weight. He doesn't do pelvimetry. He used to, but he found it distracted him from the criteria of labor progress. He uses continuous monitoring during labor. If a woman strongly does not want cEFM, they will come to a compromise agreement.

Dr. Martin Gimovsky agreed with everything Bisits said. In addition, he can never stress enough the importance of support people (labor nurses, doulas) besides midwives and physicians. The key to VBAC or VBB is to go for the low-hanging fruit. He'd much prefer a mutlip frank breech than, say, a primip footling breech that weighs 4000g.

He was trained to measure the pelvis for all babies. He uses cEFM and CT pelvimetry. With a breech baby, a prolonged active phase of labor is a sign for concern. Dilation: the cervix dilates as the muscle fibers are taken into the uterus, not depending on the presenting part. Thus he feels epidurals are acceptable if the patient uses them. They do cord gases after the birth. The pediatricians are always unhappy with him and others who do VBB. An ideal candidate: frank breech, 37-42 weeks, EFW under 4 kg, woman comes in in active labor. Primips or multips are okay. He is more concerned than others about pelvic capacity and feels a CT scan is advisable.

Primary principle: first do no harm
Second principle: patient autonomy

Midwife Jane Evans noted that her parameters as a midwife are wider since they take on women who have no option of VBB in a hospital. Her first prenatal visit is 2-3 hours long. She ensures women have all the information on all of their options. She only has access to one hospital in her area, so mostly vaginal breech birth is done at home. Many of the women want to start labor spontaneously. She doesn't have a criteria for the baby's presentation. If a footling comes down too early, have the mum lie on her left side and tickle the foot gently. The baby will tuck it it back up inside. As long as we have progress throughout the labor and 2nd stage (and don't forget the placentas!) and baby and mom are okay, we await and facilitate the birth.

Q: What size of babies are you catching breech?
Her breech babies range from 2750-5000g. The average weight is probably 3000-3500 g. If a nice fat, well-grown bum doesn't go through, the head won't go through. IUGR is a contraindication; she uses her hands to determine this. She "palpatimates" the size of the baby. She feels she's more accurate than a scan in determining IUGR.

Dr. Sophie Alexander of Belgium remarked that she works in an entirely different context from Jane Evans. In her country, if a woman has a breech baby, the guidelines say you have to offer or discuss the option of a VBB. Most of their criteria have evolved from tradition as taught by older OBs. She follows her College guidelines strictly. These include:

• Routine scan at 32 weeks to determine presentation
• 32-37 weeks if breech
• talk with mother/parents
• discuss options if baby remains breech and ECV fails. Give her access to full information (i.e., TBT and PREMODA)
• tell her she can use positional or moxa interventions but there is not good evidence
• reinforce motivation for physiotherapy (kinesitherapie) unless she is really sure she prefers and elective cesarean section
• Attempt ECV at 37 weeks, unless woman has objection or contraindications
• If ECV fails,
• CT or MRI pelvimetry
• Ultrasound for EFW
• Prenatal visit to explain the process of breech, emphasize the need for teamwork

Criteria for vaginal breech birth at term:

• Adequate pelvimetry
• EFW 2500-3800g
• Not footling
• Flexed head in labor
• In Belgium, there are mixed practices on allowing primips, nuchal cords, and full (complete) breeches
• A previous cesarean will have a repeat cesarean if labor doesn't begin by 42 weeks

Admission guidelines:

• Confirm frank or complete (full) breech
• Confirm head flexion
• Be sure labor is well-established before admission

In labor:

• If the woman departs from the partogram, allow only twice two hours to get back into a normal labor pattern. Can augment with oxytocin for 2 hours. If still no progress, try ARM and wait 2 more hours. If still no progress, suggest cesarean section.
• Epidural is a general rule for all women attempting VBB
• At 9 cms, inform the OB, pediatrician, anesthetist, & midwife
• At full dilation:
• allow passive 2nd stage for up to 60 minutes
• then put up oxytocin drip and start pushing
• pushing should bring some descent within 20 minutes and birth within 60 minutes, otherwise move to cesarean
• birth should be expedited if there are anomalous FHR or breathing attempts

Dr. Alexander acknowledged that these guidelines are quite strict. However, vaginal breech birth is politically delicate and one bad outcome could mean the end of VBB. They have to be careful to stick to the rules--as much as she has some personal frustrations with them. 

Dr. Marek Glezerman commented that we all want mostly universally acceptable criteria. In Israel, he has no choice but to adhere to the guidelines (which he helped write!). Choosing the right vaginal breech patient means you're already there-you already have the skills, the motivated patient, and the safety net. Unfortunately we're not all in this ideal situation yet.

He posed some interesting questions:

• What about emergency breech delivery, where there's no time for choice or discussion? What if you have no access to skills on premises?
• What about comparative risk assessment?
• How do we convince OBs, the public, or the courts that VBB is a viable option? Don't ignore the reality of the medico-legal environment. We need to convince courts that risk assessment means looking at all aspects of the situation, not just at the risks of vaginal breech birth.
• And most importantly: Why are there so few OBs in this room? The conference organizers said there were 10 OBs in attendance, not counting the speakers. But there should be hundreds at this conference!

Dr. Glezerman also contrasted the ideal world vs the real world. If you cannot avoid complications or disaster, you better be prepared. There will always be situations where you need to deliver breeches vaginally. Unfortunately, we have buried or lost our skills. Three generations of residents have never had the chance to learn VBB, so we cannot offer choices. Everyone is on their own.

Ethical limits of autonomy:
Autonomy means both the right to choose and the right to refuse treatment. But it's not the same as the right to demand treatment. (I wish he had further expanded on this point. Is a vaginal breech birth "demanding treatment"? Or is the inevitable consequence of refusing a cesarean--since it will occur on its own? These questions apply equally well to VBAC, since refusing an elective repeat cesarean will inevitably end in a vaginal birth after cesarean, making it less of a "treatment" and more the physiological result of pregnancy.)

How do we convince those who are opposed to offering vaginal breech birth?
We need to use the right tools. We can't use only moral reasoning. OBs have been trained to listen to data. We have to focus on the risks involved with cesarean sections. CS is not just another delivery mode; maternal mortality for elective CS is 3x higher than for vaginal birth. There are incidental and consequential morbidity from cesarean surgeries. What price does the public pay for higher rates of CS? Cesareans have an impact on future reproduction, higher maternal mortality and morbidity, longer hospital stays, higher stillbirth rates, placental abruption, placenta previa, and more. 

Placental pathology is "The Great Risk Factor" with cesarean section.
50% of all emergency hysterectomies are done for placenta previa or placenta accreta. The risks increase exponentially with each additional CS. Overall, cesarean section carries more risk for the mother than a vaginal birth. If so, is it better for the baby? No. Cesarean section is associated with higher fetal/newborn morbidity, respiratory problems, bonding/feeding problems, prematurity, etc. There is unequivocal data showing increased risk to the baby from cesarean section. 

Arguments for reviving vaginal breech birth:

• Because CS is more risky for mother
• In well-chosen women there is no advantage for the baby compared to CS
• There is not always a safe alternative
• Women's right to choose
• For when CS isn't an option
• For the second twin
• To reduce unnecessary CS
• To prevent subsequent CS
• During a cesarean surgery: you still need to be skilled in breech delivery techniques to be able to delivery a breech baby or a deeply lodged vertex baby safely!

He referenced several studies:

• Chopra S et al. Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: Conventional method versus reverse breech extraction. Acta Obstetricia et Gynecologica Scandinavica. 88.10 (Oct 2009): 1163-1166.
• Kolas et al. Planned cesarean versus planned vaginal delivery at term: Comparison of newborn infant outcomes. AJOG (2006) 195, 1538-43.
• Rageth et al. Delivery after previous cesarean: a risk evaluation. Obstetrics & Gynecology. 93.3 (March 1999): 332-337.

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