Friday, June 23, 2017

Articles on informed consent, autonomy, and forced/coerced interventions

I have discovered several recent articles about autonomy, informed consent, and forced/coerced interventions during childbirth that I highly recommend:

Also some older articles that are still relevant and useful:
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Thursday, June 22, 2017

The Vermelin method of vaginal breech birth

While translating this French article about nonfrank breech birth, I came across a reference to the "Vermelin method" of breech delivery. The author referred to Vermelin as if it were common knowledge--and it is, apparently, in the French obstetrical tradition. I found three theses from French-speaking midwifery or medical students that explained the Vermelin method.

In 2010, Jennifer Thomé wrote a thesis (PDF) as part of her midwifery degree from the Ecole des Sage-Femmes de Bourg en Bresse. She wrote:
Vermelin's non-interventionist method
Expulsion then takes place through uterine contractions and maternal expulsive efforts.

The operator attends the physiological delivery as described above and plays the role of "attentive observer," ensuring that dystocia does not occur. See appendices I and II.

A hard surface is placed under the perineum to receive the fetus.

The practitioner can pull down a loop of cord as soon as the abdomen has emerged and perform a Bracht maneuver to assist the expulsion of the fetal head, preceded or not by a Lovset maneuver (Lansac 2006). (p. 13-14)

France takes part in the approach of not using any systematic prophylactic maneuvers but instead resorts to them in cases of dystocia (DuBois 1990). For Bracht in 1938, "the number and the precocity of interventions" during the birth of the breech was the cause of the high fetal mortality rate; he therefore advocated abstention from maneuvers and promoted spontaneous emergence of the fetus for as long as possible. In 1948, continuing Bracht's advocacy, professors Vermelin and Ribon of Nancy also advocated spontaneous breech birth, showing that childbirth can take place entirely spontaneously; the hands-off "Vermelin method" was fairly widely adopted. (p. 17)

Appendix I: Spontaneous birth of the frank breech. 

Appendix II: Spontaneous birth of the nonfrank breech
Both illustrations are from Lansac J, Body G, Perrotin F, Marret H. 
Pratique de l'accouchement, 3ème éd éditions Masson, mai 2001.

In 2011, Marie Moncollin of the University Henri Poincaré in Nancy wrote a thesis (PDF) for her MD degree. She largely echoed the same points in Thomé's thesis.
At the beginning of the 20th century, most authors considered the breech presentation to necessitate obstetric intervention: prophylactic lowering of the foot, full extraction or release of the arms as promoted by Lovset in 1937. In 1938, Bracht reacted to this attitude and advocated abstention until expulsion. He then presented his maneuver for freeing the head, which we shall discuss later.

In 1948, the authors Vermelin and Ribon of Nancy defended an even more absolute abstention from obstetrical maneuvers. For Professor Vermelin it was important not to see pathology where it did not exist. While breech delivery was considered abnormal, even obstructed, at the time, Professor Vermelin wanted to show that a breech delivery could unfold in its entirety without intervening at all. He demonstrated that Mauriceau's maneuver, apparently innocuous, could be the starting point of cerebro-meningeal lesions, neonatal death factors, or psychomotor sequelae, and that it was better to do without the maneuvers. Thus Vermelin's technique of spontaneous delivery of the breech remains a classic for obstetricians of the Ecole de Nancy (see Vermelin 1956). (p. 28)

We have seen that the School of Nancy was marked by the Vermelin technique for the birth of the breech (he was a professor at the Maternité de Nancy from 1943 to 1961), but what about 50 years later? (p. 67)
Moncollin notes that French obstetricians today are not as hands-off as Vermelin advocated for; they generally assist with the birth of the arms and the head:
The birth of the breech according to Vermelin (1948) consisted of complete abstention from maneuvers. Thus, no maneuvers were practiced. However, to prevent asphyxia in the fetus, it is now advisable to finish the delivery, when the point of the shoulder blades appears in the vulva, by releasing the arms that are in the vagina and then the head. The Lovset (1937) maneuver will facilitate the expulsion of the shoulders, then the Bracht (1938) or Mauriceau (1668) maneuvers will free the fetal head. (p. 53)
She also makes this comment about breech birth at home:
Home birth:
Do not touch the breech presentation if obstetric maneuvers are not perfectly known. In this case, it is advisable to adopt the Vermelin maneuver. (p. 66)

Finally, a 2015 MD thesis by Daouda Aliou Kone (PDF) repeats the same information about Vermelin found in the other two theses.

  • Dubois J, Grall J-Y. Histoire contemporaine de l’accouchement par le siège. Rev. Fr. Gynecol. Obstet, 1990; 85(5): 336-341.
  • Kone DA. Etude épidémio-clinique et pronostique des accouchements par le siège dans le centre de santé de référence de la communie II du district de Bamako. Thèse pour le Docteur en Médicine. Université des sciences, des techniques et des technologies de Bamako. Faculté de médecine et d’odonto-stomatologie. 6 Jan 2015.
  • Lansac J, Marret H, Oury J-F. Pratique de l'accouchement, 4ème édition, Paris, Masson 2006 553p: pp 125.
  • Moncollin MM. Choix de la voie d’accouchement en cas de présentation du siège: évaluation des pratiques cliniques à la Maternité Régionale de Nancy en 2008. Thèse pour le Docteur en Médecine. Université Henri Poincaré, Faculté de Médecine de Nancy. 11 Oct 2011.
  • Thomé J. La présentation du siège unique à terme: enquête sur les politiques de prise en charge des maternités du réseau AURORE. Université Claude Bernard Lyon 1, Faculté de Médecine Rockefeller, École de Sages-femmes de Bourg en Bresse. 2010.
  • Vermelin H, Ribon M, Facq J. Présentation du siège complet avec déflexion primitive de la tête; dégagement spontané en occipito-postérieure. Gynecol. Obstet. 1948; 47: 1250-1253.
  • Vermelin H. [The teaching and practice of the gynecology and obstetrics specialty] [Article in Spanish]. Tokoginecol Pract. 1956 Oct 15 (145): 569-81.

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Monday, June 12, 2017

A car birth, a bus birth, a yurt birth, an en caul birth, and a mother-supported birth

This reminds me of a Dr. Seuss book...
I can give birth in a car
I can give birth in a bus
in a yurt
with the caul
with my mom
A car birth
An Australian family pulls over onto the side of the road and has their baby in front of an apple shop.

A bus birth

A yurt birth
Through June 18, you can have your baby in this fully-equipped yurt in the middle of the Amsterdamse Bos. No charge to use the yurt. Sponsored by Birth Project: Look Again, which is hosting a number of activities in June. More information here.

An en caul water birth
The father lifts the caul off his daughter's face after she is born. Watch the video and read the birth story.

A mother-supported birth
A mother supports her daughter having her second home birth

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Sunday, June 11, 2017

Urgent--I need a Hamilton-style pregnant silhouette

Dear pregnant readers--I need your help! I need a photo of you, with your gorgeous pregnant belly, posing like Alexander Hamilton. Posed just like this, or as close as you can get and still clearly show off your belly.

Tight-fitting clothing is best. Bonus points if you are wearing tall leather boots!

I need a head-to-toe shot. Doesn't matter what's in the background as long as it's easy to distinguish between you and everything else (I will be turning it into a black-and-white silhouette).

To be used for an awesome project TBA.
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Wednesday, June 07, 2017

Breech and the art of obstetrics

Sometimes doing research is really, really boring. Other times I come across gems like this 1961 Lancet article titled "Management of Breech Presentation" by Leonard Lang. His humor and colorful language bring his words alive, contrasting with the dusty pages they now live on.

Also worth reading is his commentary on the last page about the trend towards increased cesarean for breeches.

The old masters in obstetrics of one or two generations ago—the mean who taught many of us—had a great deal of respect for the breech. Each of them had special technics and pet maneuvers that worked well in his particular hands. Each warned against certain dangers and pitfalls that should be anticipated, carefully searched for, and then properly handled, sometimes in rigid mechanical sequence. Many of these dedicated teachers had slogans and bits of advice that clearly expressed their concern. Dr. Williams often said that he could tell a really good obstetrician by the manner in which he conducted a breech delivery. Our old teacher, Dr. J. C. Litzenberg, liked to say that “any physician who said that he wasn’t afraid of a breech or never had trouble with a breech was either someone who didn’t do any work in obstetrics or was an ‘outright’ liar, and he could choose his own category!” Another exhorted the medical student to always be friendly with his competitor across the street, “because you may need him to help you with a breech some time!” They were acutely aware of the dangers inherent in breech delivery. They had to be. They had to depend upon their hands and keen mechanical sense which experience developed into a type of intuitive perception and manipulation that DeLee liked to call the “art of obstetrics.” They couldn’t readily resort to cesarean section once delivery from below was chosen. They didn’t have blood banks, antibiotics, and highly trained anesthesiologists.

No doubt our old teachers are turning in their graves as they contemplate upon the number of cesarean sections we are doing for breech today. We can only hope that St. Peter has tried to explain why things have changed. That might help a little but I’m sure that it wouldn’t completely satisfy that fine group of “Old-Timers.”
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Monday, June 05, 2017

A breech conference, 60 years ago

On November 22, 1957, the Obstetrics & Gynaecology section of the Royal Society of Medicine held a conference on breech. Conference notes were published in the March 1958 edition of the Proceedings of the Royal Society of Medicine (PDF).

It is a fascinating read. As I have been finishing conference summaries from the 2017 Sheffield breech conference, I reflected on how similar these two conferences were in spirit, although miles apart in content. I found the same collegiality, curiosity, and desire to improve outcomes. However, many of the practices seem quite out-of-date now. (Which makes me wonder: 60 years from now, what innovations discussed in Sheffield will have stood the test of time?)

I also noticed a marked gender shift in conference presenters, from exclusively male in 1958 to majority female in 2017 (with the 2017 audience predominantly female).

Here's a breakdown of speakers & topics and a "summary of the summaries," if you will. I would definitely read the originals, so I hope my brief teasers are enough to get you interested.

Dr. G. F. Abercrombie (London): The Timing of External Version. He advocates early external version beginning around the 30-32 weeks. Reports on his personal series of ECVs.

Mr. John Hamilton (Liverpool): Discusses the Burns-Marshall technique developed in and used by the Liverpool Maternity Hospital. General advice on selection criteria and labor management. A pithy statement about breech birth at home: "I will say at the outset that there is only one place for breech delivery, whether multigravida or primigravida, and that it in hospital." (Remember, at this time in England and Wales, around 33% of births still took place at home. See the UK Office of National Statstics report on home births.)

Mr. J. H. Peel (London): Makes an argument for ECV to lower the rate of breech deliveries and thus the overall mortality rate due to breech. Advocates for ECV around 34 weeks. Reports on both a personal series and a hospital series.

Mr. David Methuen (Oxford): Presents a series of 448 breech deliveries from his department in Oxford between 1952-1956. Advocates for using pudendal block or epidural anesthesia rather than general anesthesia for breech deliveries.

Mr. C. K. Vartan: Advocates for inducing all breeches at 38 weeks to produce "smaller babies which would not need to be extracted." A brief discussion of FHR after the baby is born to the shoulders.

Mr. Gilbert Dalley: Prefers ECV to breech delivery. Presented a 10-year series of births at West Hill Hospital in Dartford, both vaginal breech births and ECVs. Advocates performing ECV before the 35th week.

Mr. J. S. Hesketh: Concerned about the amount of traction described by Mr. Hamilton in the Burns-Marshall technique.

Mr. Wilfrid G. Mills: We should distinguish between extended (frank) and flexed (complete/incomplete/footling?) breech. Strong advocate of ECV, although he thinks it should be performed whenever the breech presentation is diagnosed, rather than at a set time. Gives an alternate explanation for why intracranial hemorrhage occurs in some breech deliveries.

Dr. J. Vincent O'Sullivan: Supports Mr. Peel's plea to do ECVs and suggests between 30-34 weeks. Discusses a different technique for delivering the aftercoming head by "rolling" the head over the perineum and pressing the nape of the neck close against the symphysis.

Mr. John Hamilton then replied to some of the earlier comments.

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Thursday, June 01, 2017

Obstetric Blinders: Cord Clamping

In my last post on obstetric blinders, I quoted a 1970 article that discussed upright birth among the Bantu and Polynesian people. That article quoted M.C Botha's 1968 article on the management of the umbilical cord in labor from the South African Medical Journal. (Full text here.)

I managed to track it down and was blown away by what I found--both by the evidence against cord clamping and by the obstetric blinders that Botha wore.

Botha's article begins with some quaint observations about childbirth in the Bible and other ancient literature. Botha then examines "primitive" birthing practices:
The most primitive of the Bantu people believe that it is completely wrong to touch the cord until the whole placenta is expelled. Once bearing-down pains commence, the parturient woman sits on her haunches, as if in defaecation. The trunk is bent forward, thus increasing the intra-abdominal pressure. Her bearing-down efforts are not new to her, since she has repeated the same act in defaecation daily since she was born.

Once the baby is born, the woman (Fig. 1) will remain in a squatting position watching her new baby. The placenta delivers itself from the vagina without any maternal effort (Figs. 2 and 3). Once the placenta is delivered, by gravity, the membranes usually remain in the vagina. The patient then lifts herself on her haunches and the membranes fall out. Only now does she pay attention to the cord (Fig. 4).

Hooten [1 sic] reported the same observations. Vardi [2], on account of this observation by Hooten, investigated the extra amount of blood that can be transfused into the baby by gravity; the residual blood in the placenta was approximately 11.2 ml. By bleeding the cord the total average blood volume was 100 ml. They thus concluded that by gravity, and not clamping the cord, the baby gets an extra 89 ml. of blood. This is exactly what happens in the Bantu baby.

Working among the Bantu for 10 years, attending 26,000 Bantu and seeing only abnormal cases, I found many other complications, but a retained placenta was seldom seen. If called to a case, I usually found that the terminal part only of the membranes was still in the vagina, and had merely to be lifted out. Blood transfusion for a postpartum haemorrhage was never necessary.

It gets more interesting. In the next paragraph, Bantu writes:
In accordance with this observation, the third stage of labour in White patients was managed with the use of Syntometrine [Pitocin], letting the cord bleed, and the Brandt-Andrews manoeuvre, and in 800 cases over the past 10 years no retained placenta or postpartum haemorrhage needing blood transfusion has been found. 
Note the difference in care between Bantu women (cord left intact) and White women (oxytocics, managed 3rd stage, cord clamped on the baby's side and left to bleed on the maternal side). Bantu babies also received an "extra" 90 ml of blood compared to White babies.

Let's see what else this article has to offer. I'm going to skip the next section on the history of cord clamping from the 16th century to the present. It's worth reading on your own, however.

Next, Botha discusses a study he conducted on a consecutive series of 60 unselected women, 30 with clamped cords and 30 intact cords. In both groups, "the uterus was not handled after the birth of the baby. The placenta was not handled until the mother felt the urge to bear down herself and was only received when it appeared outside the vagina. No oxytocic drugs were used." Women with intact cords birthed their placentas much more quickly and with much lower blood loss, compared to women whose cords were clamped.

Botha did another study in which he injected dye into the placenta immediately postpartum via the umbilical vein and took a series of X-rays to visualize the descent and birth of the placenta. He found that placentas with unclamped cords delivered more quickly than placentas with clamped cords.

Let's go to the end of the article, now, in which Botha discusses his findings. He begins with an unsurprising observation: "In the cases where the cord was not clamped in the third stage there was a statistically significant difference in duration and blood loss compared with those where the cord remained clamped."

Further down, he notes that an upright maternal position helps the placenta birth rapidly and with little resistance:
As there is fundal dominance in uterine activity, the placenta is forced in the direction of least resistance towards the lower segment and vagina. If the cord is bled, this process is so rapid that retraction has not yet taken place in the cervix, and the placenta, reduced in size, is expelled without resistance into the vagina. If the patient is sitting on her haunches, it will fall out by gravity.
Skipping ahead a bit more:
If the cord is clamped, counter-resistance from the placenta may be so great that retraction may come to an end. The placenta will then be separated by retroplacental blood, which, in my opinion, is not normal but abnormal. this takes place slowly and by the time the placenta is separated the cervical muscle has also retracted. The placenta is bulky, due to the blood it contains, and expulsion is difficult. If expulsion is not possible, the inevitable result is that in a certain percentage of cases the placenta will be retained, with associated postpartum hemorrhage.
Botha notes several times that the baby receives an "extra" 90 ml of blood if the cord is left intact. (I suggest phrasing it in the inverse: when the cord is clamped, the baby loses 90 ml of blood.) His next paragraph again mentions the difference in blood received by the baby:
If the cord is not clamped until the placenta is expelled, the baby will receive an extra amount of blood, which is approximately 90 ml., as reported by Vardi. 
He also notes that Rh- sensitization is rare when the cord is left intact and the placenta is birthed spontaneously.

The conclusion is fascinating--and disturbing--in how firmly Botha's obstetric blinders were in place. I had expected his conclusion would recommend leaving the umbilical cord intact until the placenta is birthed. This would both reduce both retained placenta and postpartum hemorrhage and give the baby its full blood volume. But instead, Botha recommends a surprisingly complicated method of third stage management:

Ironically, midwives would be giving superior care by simply leaving the cord intact and waiting for the birth of the placenta, because the baby would also retain 90 ml of blood in the process.

This is a classic example of how "modern" obstetrics pursues an invasive and complex solution (oxytocic drugs, bleeding the placenta, removing the placenta with controlled traction and pressure on the uterus) while discarding the simpler, better solution (leaving the cord intact and waiting for the placenta to birth on it own)--even though the "primitive" solution is easier for the attendant and better for the baby. 

  1. Hooton, Earnest A. Man's Poor Relations. 1st ed. New York: Doubleday, 1942. p. 412. (Corrected from the original)
  2. Várdi, P.: Placental transfusion: an attempt at physiological delivery. Lancet 2:12–13, 1965.
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Julia & Harry: Having our breech babies in Sheffield

Julia & Harry
A parent's view: Having our breech babies in Sheffield
North of England Breech Conference, Sheffield
Day 2

We had a lovely family talk about their two breech births: Julia & Harry. Julia first talked about the birth of Frank, her oldest, who is now 2 1/2. They had been trying to get pregnant for around 4 years and finally succeeded with AIUI. The whole process was very involved medically, with lots of scans and visits, and emotionally stressful.

They found out Frank was breech around 28 weeks, but initially Julia's providers told her not to worry, he might turn. Julia tried all sorts of natural techniques to encourage him to turn: moxabustion, acupuncture, inversions, swimming upside down, etc. Her providers booked her in for a cesarean, and at that point Julia's whole world crumbled. She hadn't realized how much emotional stress she was carrying. That last straw—to say we’re going to just come in and take your baby out—made her feel powerless, like there wasn’t anything she could do. Her whole life she had looked forward to giving birth. It was a very primal thing. And being told that she was going to have a cesarean really upset her.

Harry: If someone tells you you can’t do something, you generally want to do it.

Julia: Julia told her midwife  that she wasn’t happy about the cesarean. She had wanted a home birth. Her midwife said, you know, there’s a team who can do breeches! She got referred to Helen Dresner Barnes and felt so relieved that she’d have a chance to try. She did lots of reading and research and read other birth stories. Julia had a cesarean booked in, so she had a bit of deadline, but at least she had a deadline and some options. Julia went into labor naturally and was in a good head space: if I needed a cesarean, it would be fine. In the end, she had her baby vaginally in the hospital. Although the whole process of pregnancy was quite hands-on, the actual delivery day was very hands-off, with no intervention by the midwives. All three of them just let her do her thing to get him out.

Two years later, they weren’t actively trying to get pregnant, and Julia wasn’t having any periods. The doctor said she’d need to go through AIUI again to get pregnant. Julia went in a week later for a bloated belly and discovered that she was 4 moths pregnant! With the second pregnancy, the midwives were more hands-off. Julia had just one scan at 16-17 weeks.

Harry: Such an opposite experience form the first pregnancy.

Julia: Julia went into labor planning a home birth and thinking her baby was head-down. Florence came within 2 hours of labors tarting. Julia had the same team of midwives, who liked to care for “repeat offenders.” She had Florence on her own. Sally, one of the midwives, arrived 10 minutes later.

Her two pregnancies were very very different experiences, from high intervention the first time and pretty much nothing the second time. Julia doesn't think the second time would have gone the way it did—the trust in herself, in her own instincts—without the first experience and having had the team there the first time.

The main thing Julia learned from her two breech experiences: "I wanted the power myself to be able to make an informed decision on what I was to do, whether it was to have a cesarean or not. You can only trust yourself if you have the support in order to feel you can trust yourself."

Harry: In hindsight with Frank, we were engaged with medical science and technology at every point. I was amazed at how instinct kicked in when labor started. And the breech team gave that space, that light touch, to let it kick in. That was the most surprising and, in hindsight, the most obvious thing I realized after Frank.

Julia: If we had known Florence was breech before she was born, there might have been more intervention.

Helen Dresner Barnes: I learned that Julia had a breech birth when I came into her home. Julia told me, “It was okay; I recognized what was happening. I don’t know what I would have done if the baby was head first!”
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