Breech Research: Heads Up! Breech Conference

To contact us Click HERE
Day 1:Panel on Breech Research: Looking Back and Looking Forward
Dr. Andrew Bisits

Andrew Bisits presented data from term breech presentations at John Hunter Newcastle Hospital collected between October 1999 - December 2010. He compared outcomes of planned vaginal breech birth (VBB) vs. planned cesarean section (CS). He noted that this was a retrospective audit, so there are limits to the data collection and validity. Overall, 1,016 women presented at his unit with a live singleton breech fetus at term (37+ weeks). Some births were excluded, leaving 766 cases for analysis: 243 planned VBB and 523 planned CS. 58% (n=141) of planned VBB ended up delivering vaginally, while 42% (n=102) had a cesarean section in labor. A very small number of planned cesareans (n=5) ended in a vaginal breech birth.

He noted that this study group had a high rate of induction (31.3%) and augmentation (28.0%) in the VBB arm. The most common pain relief methods were nitrous oxide (39.5%), spinal anesthesia (28.8%) and narcotics (17.7%). Most women adopted an upright position, with 70.2% on a birth stool and 2.8% on all fours. 34% of the births required some sort of maneuver: MSV was the most common (29%), followed by Lovsett (17%) and supra pubic pressure (4.3%). Serious perineal trauma was fairly rare, with only six 3rd or 4th degree tears out of 141 births.

Some conclusions from the data:

• In planned vaginal breech births, 1.25% of babies experienced significant morbidity. No baby was harmed long-term. 
• Maternal morbidity in pVBB was around 8%; much of this was due to in-labor cesareans (incision extensions, wound infections, vertical uterine incisions, etc.)
• 60% of planned VBB ended vaginally. 

Dr. Bisits suggested some future directions for research and training, including good rigorous prospective data collection, ultrasound study of births, use of high quality simulation models, and qualitative research into women's experiences of breech.

Last, Dr. Bisits commented that the physicians during this time period (1999-2010) had to be very cautious because of the delicate political situation surrounding breech birth. They were under quite a bit of pressure to react at the slightest sign during a breech labor.  He was surprised by how happy  women were to have had a chance and a choice, even if they ended up with a CS after attempting a VBB. 

Dr. Anke Reitter


Dr. Anke Reitter began by briefly reviewing the implications of the TBT in Germany. She wasn’t very shocked by the findings of the TBT, based on how it was designed. There has never been a strong breech advocacy community in Germany; she doesn’t think anything like the Coalition for Breech Birth would be possible there. She also mentioned Marek Glezerman’s 2005 critique of the TBT, Five Years to the Term Breech Trial, which she felt was extremely important in changing the course of breech birth. In Germany, the rate of VBB fell after the Hannah Trial. Multips had a small but decent chance at VBB before the TBT, while primips rarely did, even before 2000.

She told Dr. Frank Louwen’s moment of inspiration when he looked at illustrations of vaginal breech births upside-down. He realized that if we turn a woman over, we won’t have to do as many maneuvers and that the breech can deliver itself. Dr. Reitter need new terms for this new spontaneous kind of birth on H&K.

Pelvic MRI
Next, she presented the results of a research study on maternal positioning and pelvic dimensions. (A. Reitter, A. Schollenberg, K. Eichler, M. Larson, F. Louwen, T.J. Vogl, S. Zangos. "Pelvic MRI in Pregnant and Non Pregnant Women: A Prospective Study.") They measured 100 women's pelvic dimensions in supine and upright positions: 50 were pregnant and the other 50 were non pregnant volunteers (mostly midwives from her unit). Because the MRI had limited space, they couldn't have a woman up on her hands and knees. The modified position looked like this:

The research team found significant differences in pelvic dimensions depending on maternal positioning. In the modified hands & knees, the anatomical diagonal and conjugates become shorter, while all other pelvic parameters become wider. "These changes are significant," according to the research team. 

What does this tell us? If we change the position of the mother, something in her pelvic changes. The increase in size is even more pronounced in pregnant women.

She briefly referred to another study using MRI for breech presentations (Van Loon et al. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term. Lancet 1997; 350: 1799-1804.) This study concluded that using MRI did not significantly reduce the overall cesarean rate, but it did lead to a lower emergency cesarean rate during labor.

New Maneuvers for Breech
Anke outlined two new maneuvers for freeing nuchal arms and flexing the head. It started with this scribble by Dr. Louwen. He had observed that a breech baby that rotates spontaneously to Sacrum Anterior ("normal") will not have arms behinds its head. However, if the baby does not restitute to SA and remains turned oblique ("pathol"), one or both arms are likely trapped behind the head.


Anke commented, "When it stays transverse and doesn’t rotate on maternal pushing, you have a major problem. This is a sign to be prepared to interfere." It’s important to closely know the signs of a spontaneous physiological breech birth so you can pick up on abnormalities.

She and Frank developed an illustration based on these initial observations, with two new maneuvers: Louwen's maneuver (grasp the shoulder girdle and rotate baby180 degrees clockwise, then 90 degrees counter-clockwise to Sacrum Anterior) and Frank's nudge (press the shoulders straight backwards---not downwards--to cause the baby's head to flex against the maternal pubis symphysis). This illustration shows the normally descending baby on the upper left, and a problematic presentation on the upper right.

The Frankfurt clinic currently does 2-4 vaginal breech births per week. To get more hands-on training with these maneuvers (most of the breech births they attend are spontaneous and require no maneuvers), they have turned simulation training. They use an obstetrical birth model and turn it over for H&K positioning. Here's a slide showing a simulation workshop:

Preliminary results from the Frankfurt clinic
Anke briefly presented the results of the 750 term singleton term breech babies at their unit occurring between January 1, 2004 - June 30, 2011. She and Betty-Anne Daviss discussed this research more in depth the following day, so I will just summarize the main findings. 437 women planned a vaginal birth, and 276 (63.1%) were successful. In both the planned CS (n=313) and planned VBB arms, deaths occurred only among fetuses and neonates with lethal anomalies. 17.4% of upright breech births required maneuvers, compared to 67.7% of on-the-back breech births. Based on these results, they conclude that maternal upright or hands & knees position may:

• Provide a physiological advantage during vaginal delivery. 
• Decrease manual maneuvers required to extract the body of infants in breech position and resulting birth injuries. Positioning and maneuvers for the delivery of the head might remove the necessity of forceps in breech. (During this 8 1/2 year study period, the Frankfurt unit never used forceps.)
• Reduce fetomaternal complications in term breech delivery because umbilical cord is less influenced by compression in the second stage (less frequent CTG abnormality)

Marek Glezerman

He still keeps talking about the TBT 12 years later because so many of his colleagues still cite that article and don’t acknowledge any of the newer studies. He spent most of his presentation outlining the strengths and weaknesses of the TBT. I highly recommend reading his 2006 article Five Years To the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial (full text PDF here).

The TBT was a perfect fit for the medico-legal climate in obsetetrics at the time. It was fast-tracked for publication in only three weeks. Almost overnight, the entire Western world stopped doing vaginal breech births. In contrast, the 2-year followup study (White et al) took 2 years to be published. This study found that planned CS is not associated with reduction of risk of death of neurodevelopmental delay in children 2 years of age, “but more parents in the PCB groups than the PVB group reported that their children had had medical problems in the past several months.” Even though this analysis found no difference in long-term outcomes, it was too late. Except for a few isolated hospitals and providers, vaginal breech birth had gone extinct.

Dr. Glezerman's 2006 critique of the TBT attracted a lot of heat. But it also was highly influential in softening ACOG, RCOG, SOGC, and Cochrane guidelines on vaginal breech birth.

Ohter articles Dr. Glezerman referenced:

• Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol (2002) 99: 1115–1116. 
• Whyte H et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial. Am J Obstet Gynecol (2004) 191(3): 864-71.
• Schutte JM et al. Maternal deaths after elective cesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand. (2007) 86(2): 240-3 . This study found that ECS does not guarantee the improved outcome of the child, but may increase risks for the mother. Cesareans for breech presentation was responsible for 7% of total direct maternal mortality in that period (4 maternal deaths in 3 years). 
• Goffinet F et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. AJOG (2006) 194: 1002-11. Usually referred to as the PREMODA study. Dr. Glezerman commented that a good ITT (intention to treat) study, such as PREMODA, is certainly is much better than a bad RCT. 

Marek ended his presentation with a call for reviving vaginal breech skills. These skills are essential not just for women who actively seek VBB or who present late in labor with an undiagnosed breech. Physicians also need them during cesarean sections.

He discussed a fascinating study on difficult vertex cesarean sections when the baby's head is deeply lodged in the pelvis. Obstetricians typically use the "push/pull" maneuver (push the baby's head up out of the pelvis, and then pull the baby out of the incision head-first) to deliver the baby. However, this method is associated with 10x greater maternal trauma than a with a "reverse breech extraction"--where the obstetrician delivers the vertex baby bum-first from the fundus.

Here's more information on the study. Email me if you'd like the full text.

Citation: 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.

Abstract:Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as ‘cephalic’ with or without assistance to push up the fetal head from the vagina (head first or push method) and ‘reverse breech extraction’ (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at ≥7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during ‘cephalic’ delivery as compared to ‘reverse breech extraction’ (22.8% versus 2.2%; p = 0.001). Use of ‘reverse breech extraction’ is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.