Heads Up! Breech Conference

Debate: Is breech pathological or a variation of normal?

November 11, 2012

Marek Glezerman and Betty-Anne Daviss, Moderated by Ken Johnson

After two intense days of learning and discussion, we were all ready to let our hair down a bit. Dr. Marek Glezerman and Betty-Anne Daviss engaged in a debate that was both earnest and hilarious. Ken Johnson (Betty-Anne's husband) heckled his wife for wearing "attire unbecoming a midwife" (she was dressed in asymmetrical layers of purple and green, evoking a tree sprite) and for unfairly influencing the audience when she signaled Dr. Andrew Bisits to stand up and begin playing his violin. But behind the silliness was an earnest question: is breech pathology or simply a variation of normal? What are the implications for how we understand and categorize breech?

Marek Glezerman opened the debate, arguing that the answer to this question has consequences. Why should he enter this mine field of a questions? If you want to struggle for the right cause, you should address the existing concerns by refuting them or handling them.

Personal experience isn't a very scientific place to start, but it's still important. He started his residency 39 years ago and has since headed three OB/GYN departments. Over those years, he's been the chair for around 200,000 deliveries. The chairman's position is important because all adverse outcomes eventually land on his desk.

He next discussed several studies on breech presentations:

• Schutte et al, 1985 compared malformations between breech and vertex presentations. They found more malformations at each gestational week with a breech presentation than with a vertex. Schutte observed: "It may be that breech presentation may not be coincidental but rather a product of the quality of the infant...if there is some truth in this supposition, it is unlikely that medical intervention ... can improve the outcome." (Schutte MF, van Hemel OJS, van de Berg C, van de Pol A. Perinatal mortality in breech presentations as compared with vertex presentations in singleton pregnancies: an analysis based upon 58,189 computer-registered pregnancies in The Netherlands. Eur. J. Obstet. Gynecol. Reprod. Biol. 19 (1985): 391-400.)
• Breech delivery is associated with more anomalies and higher mortality rates, irrespective of delivery mode. Remember that association is not necessarily causation. About 20% of breech presentations can be explained by these anomalies; the rest are unexplained. Breech presentation is an independent risk factor for neurological pathology and cerebral palsy, irrespective of mode of delivery.
• Ochschorn et al, 2009: found that length and coil numbers in the umbilical cord were different in breech vs. vertex presentations. The cords were shorter (57 v 64) and had fewer coils (5 vs 12). We don't know the significance of this phenomenon, just that it exists. (Ochshorn Y et al. Coiling characteristics of umbilical cords in breech vs. vertex presentation. J Perinat Med. 37.5 (2009):525-8.)
• Another interesting study by Sekulić et al found decreased expression of fetal movements in the first few days of life in breech presenting babies (all born via CS) which cannot be explained by anything else. We don't know the important or reasons behind this phenomenon. He'd love to see more long-term studies of breech babies vs. cephalic babies in all aspects. (Sekulić S. et al. Decreased expression of the righting reflex and locomotor movements in breech-presenting newborns in the first days of life. Early Hum Dev. 85.4 (Apr 2009):263-6.)
• Haruta et al compared breech and vertex babies born by elective cesarean. The breech presenting babies had lower umbilical arterial oxygen levels, more hypoxemia, and lower 1 minute Apgars. (Haruta M et al. Umbilical blood-gas status at cesarean section for breech presentation: a comparison with vertex presentation. [Article in Japanese] Nihon Sanka Fujinka Gakkai Zasshi. 41.10 (Oct 1989): 1530-6)
• Kean et al found that breech babies at term had more state transitions in utero than vertex babies. They concluded that "breech babies are different." (Kean LH et al. A comparison of fetal behaviour in breech and cephalic presentations at term. Br J Obstet Gynaecol. 106.11 (Nov 1999): 1209-13.)

Conclusion:
We know that breech babies are different. What is the key to that lock? Is it a cesarean? Glezerman argued no--there's no connection between mode of delivery and these differences. So is breech a variation of normalcy? No. Is it pathology or associated with pathology? Sometimes yes, but not all of the time. But we can say that "Breech babies are different."

Breech presentation is not a variation of normalcy; that's using the wrong tool for the right goal. Breech presentation may be the result, not the etiology, of pathology. Patients need to be informed, and courts need to be informed. A persistent breech presentation may need special attention. But cesarean section is no panacea.

We need more long-term prospective data on babies born breech and on persistent breech presentations. We also need to distinguish between statistical and clinical significance. There are many statistical significances in breech presentations that have no clinical significance.

Betty-Anne Daviss asked: Whom does pathologizing the breech serve best? Whom does it harm? To answer that question, she outlined the "3 Ps of corporate global society": Privatize, Professionalize, and Pathologize. (This was a play on words on the 3 P's of birth: Passenger, Power, and Pelvis.)

1. Privatize: World Trade & World Bank
Our world is seeing increased privatization of education and health care. Health care has become a big business, and interventions are sold as commodities. She discussed the 2012 WHO report by Lauer et al on what drives demand for cesarean section. Are cesarean rates rising because of women's choices? They found that the demand-side model is much smaller than previously reported. the supply-side model has some modest effects on cesarean rates; the more it's available, the more it will be used. But they found that health system factors have the largest impact on cesarean utilization rates. These factors are institutional and related to the legal environment in which health-care decisions are made. They concluded that the debate about patient choice vs. doctors' preferences isn't the right question; "health system factors may be an important overlooked population-level determinant." They suggest that cesarean rates might be most amendable to change through modifying health-care policy. (Lauer JA et al. Determinants of caesarean section rates in developed countries: supply, demand and opportunities for control. World Health Report (2010) Background Paper, 29). 

2. Professionalize:
The 3 original modern professions were the clergy, lawyers, and doctors. Now everyone's trying to professionalize--midwives, doulas, childbirth educators, lactation consultants, and more. She discussed Inuit responses to professionalizing their birth attendants: "licenses are for fishing; why would you want to professionalize midwives?"

3. Pathologize
Pathologizing what used to be normal life events is endemic in our society and particularly affects women.

Next, Betty-Anne discussed three legal cases involving breech births, illustrating how a pathological model of breech adversely effects both parents and birth attendants, regardless of whether there is a bad outcome. I don't have sufficient information about these cases to discuss them here, but I will list the key details and suggest further research if you're interested:

• Alison Osborne vs. the State of California, 1999
• ____ (midwife) vs. Washington State: Sorry, I don't have any more details on the case name or date. It happened at a time when many women were having unassisted births for their breech babies because they could not find any hospitals willing to do breech births. A midwife attended a breech birth and transported for a prolonged 2nd stage; there was no bad outcome. She was put on trial, and the verdict was, interestingly, that "the midwife needs to learn how to do footling breeches before she continues to do home birth breeches.
• Ruth Abigail Light, 2010, Illinois: baby removed from parent's custody because the parents had a breech birth at home.

Conclusion:
Breech presentation carries a higher risk than vertex presentation, but we shouldn't necessarily pathologize it. We should instead approach breech from an informed choice perspective. We need to look at absolute and relative risk. Rather than pathologize the breech, we need to pathologize cesarean sections. We also need to address the undocumented severe mental health disorders stemming from traumatic births and lack of choices.

Marek's response: He's convinced that 70-80% of women don't need a hospital to have their babies safely, while 20% of them do. Our problem is we don't know in advance who will need hospital care. We've constructed our whole maternity care system for those 20%. When he started his residency, perinatal mortality and morbidity were much higher than they are today. Let's not just blame medicine, since it has done a great service in bringing down mortality and morbidity rates.

Our problem is not black and white. Breech is not absolute pathology or absolute normality; it's in the gray zone. Residents need much more skill and experience to learn vaginal breech birth than to learn how to do a cesarean section.We need to re-skill our physicians.

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