Friday, October 13, 2017

Michel Odent on breech

Whenever I pull Michel Odent's book Birth Reborn off the shelf, it feels like phoning a dear friend after a long absence. We catch up on life and I remember why I enjoy this person so much.

Michel Odent is a French surgeon and obstetrician who was in charge of the Pithiviers Maternity Unit for over 20 years. At a time when cesarean rates were rising and births in France were highly medicalized, Odent turned the maternity wing at his state hospital into a haven for undisturbed, physiological birth. Most of his changes were low-cost and low-tech: creating an environment in which women were private and completely undisturbed during labor. He replaced delivery tables with big, low mattresses and cushions, birth pools, and simple furniture to aid spontaneous movement. His maternity unit had a 6-7% cesarean rate during the 1970s and 80s, even though it accepted an unscreened population.

I just opened Birth Reborn after a good year or two and turned to a section on breech birth. In his words and photos (pages 103-105 in the 2nd edition):


Finally, within the realm of labor and birth, one quickly learns to expect the unexpected. Sometimes a woman will have a quick and easy labor when professionals believed only a cesarean was possible. For example, women who have previously had a cesarean are sometimes told that they will always give birth that way. Yet at our clinic, one out of two women who have previously had cesareans succeed in giving birth vaginally. Nor do breech deliveries always justify the operation, although this has, nevertheless, become almost the rule in many conventional hospitals. From our experience with breech babies, we have found that by observing the natural progression of first-stage labor, we will get the best indication of what to expect at the last moment. This means we do nothing that will interfere with first-stage labor: no Pitocin, no bathing in the pool, no mention of the word "breech." If all goes smoothly, we have reason to believe the second stage of labor will not pose any problems. Our only intervention will be to insist on the supported squatting position for delivery, since it is the most mechanically efficient. It reduces the likelihood of our having to pull the baby out and is the best way to minimize the delay between the delivery of the baby's umbilicus and the baby's head, which could result in the compression of the cord and deprive the infant of oxygen. We would never risk a breech delivery with the mother in a dorsal or semi-seated position.

If, on the other hand, contractions in the first-stage labor are painful and inefficient and dilation does not progress, we must quickly dispense with the idea of vaginal delivery. Otherwise we face the danger of a last-minute "point of no return" when, after the emergence of the baby's buttocks, it is too late to switch strategies and decide on a cesarean. However, although we always perform cesareans when first-stage labor is difficult and the situation is not improving, most breech births in our clinic do end up as vaginal deliveries.

Here is a brief video of a breech birth at Pithiviers. Notice that the baby does not rotate to sacrum-anterior after the trunk is born (the most likely culprit is a nuchal arm). Odent steps in right away and frees the arm. The baby is born very quickly.

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Thursday, October 05, 2017

Benjamin Pugh's air-pipe: If you can't get a breech baby out, get the air in

English obstetrician Benjamin Pugh (1715-1798) is best known for inventing curved obstetric forceps and for his 1754 book A Treatise of Midwifery (PDF). He is less well known for innovating two ways to bring oxygen to a breech baby with a trapped after-coming head.

Pugh first created a flexible curved air-pipe, which would be inserted into the baby's mouth to the larynx. He next innovation was to create an airspace by manipulating the soft tissues inside the baby's mouth, with no need for the air-pipe.

Below is an excerpt from Benjamin Pugh: the air-pipe and neonatal resuscitation (PDF) by Thomas F. Baskett in Resuscitation May 2000;44(3): 153-155.


Although it has received less notice [than his curved forceps], Benjamin Pugh made a considerable contribution to neonatal resuscitation. In his Treatise he describes and illustrates his air-pipe (Fig. 2):
‘‘The air-pipe, as a big as a swan’s quill in the inside, ten inches long, is made of a small common wire, turned very close (in the manner wire-springs are made) will turn any way; and covered with thin soft leather, one end is introduced with the palm of the hand, and between the fingers that are in the child’s mouth, as far as the larynx, the other end external.’’
Pugh initially advocated the use of his air-pipe in cases of breech extraction during delay in delivery of the after-coming head. He used the air-pipe in the manner quoted above as ‘‘I found many children were lost in this situation, for want of air…’’ Pugh then described an alternative method which he had developed making the use of his air-pipe rarely necessary:
‘‘You must then introduce the fingers of your left hand into the vagina, under the child’s breast, and put the first and second fingers into the child’s mouth pretty far, so far, however, that you are able to press down the child’s tongue in such a manner that by keeping your hand hollow, and pressing it upon the mother’s rectum, the air may have access to the larynx, you will soon perceive the thorax expand, as the air gets into the lungs.’’
Pugh emphasised the risk of asphyxia to the fetus during delivery of the after-coming head of the breech saying ‘‘…every operator must know there is difficulty, and grave danger of losing the child by its stay in the passage; by my method of giving the child air, I have saved great numbers of childrens’ lives, which otherwise would have died’’. Furthermore, Pugh goes on to give a remarkable early description of mouth-to-mouth respiration.
‘‘If the child does not breath immediately upon delivery, which sometimes it will not, especially if it has taken air in the womb; wipe its mouth, and press your mouth to the child’s, at the same time pinching the nose with your thumb and finger, to prevent the air escaping; inflate the lungs, rubbing before the fire: by which method I have saved many.’’
Image from Baskett 2000
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Wednesday, October 04, 2017

Announcing...K. Kawai

Announcing our newest baby K. Kawai, measuring 6'8" (2 meters) and weighing in at a whopping 772 lbs (350 kg). We found a lovely church putting her up for adoption far below market value. She traveled all the way from Dayton, OH to join our family.

Ivy and Eric were present for the delivery. What an experience! It was a battle going up the front stairs, but fortunately both home and baby are doing well.

K. Kawai has her first well-piano visit next Monday. So far she's been playing like a champ, so she should only need minimal tuning.

Last month K. Kawai's older sister (7'6") had to rejoin her grandparents back in Minnesota. The house has been far too quiet since she left.

Visiting hours are afternoons from 3-5. Please bring the new parents sheet music. (We are allergic to 12-tone music, otherwise we play anything.)

We are so in love with this sweet girl.
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Tuesday, October 03, 2017

Turn-of-the (19th) century perspective on breech

My most recent discovery while digging through medical archives: a 1901 British Medical Journal article about about breech presentation by Dr. Herbert R. Spencer, an obstetrician in London. He writes about the risks of breech birth, which to a modern reader, are astonishingly high. He strongly advocates for external cephalic version as a solution to the dangers of breech presentation.

While the middle of the paper was informative, the beginning and end, quoted below, were brilliant. I enjoyed his dry sense of humor and his ability to capture the reader's interest.

The full text is available here for free download.


Professor of Obstetric Medicine in University College, London; Obstetric Physician to University College Hospital.
BMJ, May 18, 1901

Pliny in his interesting Natural History informs us that it is contrary to nature for children to come into the world with the feet first, and that those who did were called "Agrippa"' from the fanciful etymology aegre partus, or "born with difficulty." This mode of delivery was thence known as the Agrippine birth. Pliny tells us that M. Vipsanius Agrippa was almost the only instance of good fortune among those who were born in this way. "And yet," he writes, "even he was affected by the unfavourable omen of his birth, as shown by the unfortunate weakness of his legs, and his short life" (which perhaps might have resulted from his abnormal birth) "and by the wicked lives of his wife and children," which we shall be less disposed than Pliny to attribute to the mere mode of delivery. I give this quotation from Pliny as it shows the existence amongst the Romans nearly 2,000 years ago of a belief in the difficulties attending and the disabilities following delivery by the lower extremity….

[External cephalic version], of course, involves the necessity of the patient's being examined during pregnancy, a necessity which is not recognised by all doctors or patients. Yet it is time that this examination became a routine practice, for without it patients and their infants are occasionally brought into the greatest peril, and not rarely lose their lives. As a result of this routine examination conditions may be recognized which can be obviated by timely interference. I believe the presentation of the breech to be one of these conditions; and I am sure that its treatment by external version during pregnancy is so free from objection that it is worthy of extensive trial. It is in the hope that others may be induced to practise it that I have ventured to publish such a small number of cases. It would be a great gain to be able to prevent this dangerous presentation, and to be sure that the child would always present by the head; for, in the words of Pliny, it is natural for man to come into the world by the head and to be carried to the grave by the feet--"Ritu naturae mos est capite gigni pedibus efferri."

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