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In this episode, join me in delving into the intricate world of breech births with esteemed maternal-fetal medicine specialist, Dr. Emiliano Chavira. From the disappearance of breech vaginal births in modern obstetrics, to the challenges faced by practitioners advocating for this option, Dr. Chavira shares insights from his unique career path. You’ll discover the renaissance of unmedicated physiologic breech births, the ongoing struggle of the rare providers who offer this choice, and the pivotal role of hands-on vs. hands-off approaches during breech delivery. Gain valuable perspectives on who is a candidate for breech birth, techniques for handling complications, and the quest for evidence-based practices in the realm of breech births.
Resources

EBB Resources:

  • Watch the video of this podcast episode on the EBB YouTube channel here!
  • Access the EBB Signature Article: Evidence on Breech Version with a free handout here.
  • Join the EBB Pro Membership and get access to contact hours, a doula mentorship, live trainings, and a PDF Library with exclusive handouts (including a 2-page handout on breech) by joining here.
  • Learn advocacy techniques through the EBB Childbirth Class.

EBB Podcasts about Breech:

Other Resources:

  • Check out the workshops at Breech without Borders here.
  • Follow Dr. Chavira on Facebook!

Hear Dr. Chavira on The Informed Pregnancy Podcast:

Transcript

Dr. Rebecca Dekker – 00:00:00:

Hi, everyone. On today’s podcast, we’re going to talk with maternal fetal medicine specialist, Dr. Emiliano Chavira about breech births. Welcome to the Evidence Based Birth® podcast. My name is Rebecca Decker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder this information is not medical advice. See ebbirth.com/disclaimer for more details. 

Hey everyone. Before we get started, I have an exciting announcement. Tomorrow, on January 25, early bird registration for the 2024 Evidence Based Birth® virtual conference opens to the public. This is a two day conference taking place on March 22 and 23. However, if you happen to be listening to this podcast on Wednesday, January 24, I want to let you in on a secret. The waitlist for the conference has already had access to the conference for over a week and if you register by today, January 24, you get access to an exclusive bonus Q & A with me after the conference. If you want to take advantage of this opportunity that we opened up to the waitlist before it expires, go to ebbirth.com/waitlist today. If you’re listening to this later and missed this opportunity we will still have other bonuses coming up in the next few weeks, so go to ebbirth.com/conference to find out what opportunities are available to you. And now, let’s turn to today’s podcast. 

I’m so excited to introduce our honored guest, Dr. Emiliano Chavira. With extensive training in high-risk pregnancies, Dr. Emiliano Chavira has been at the forefront of care for the most challenging cases in the field. Whether it’s complex conditions affecting the baby or serious health challenges faced by mothers and families, Dr. Chavira has not only delivered exceptional care, but is also an advocate for human rights in pregnancy and childbirth. His passion extends to the realms of unmedicated physiologic childbirth, the intricacies of vaginal birth after Cesarean or VBAC, the unique dynamics of multiples, and the often overlooked arena of vaginal breech births, which we’re going to be talking about today. Dr. Chavira, welcome to the Evidence Based Birth® Podcast.

 

Dr. Emiliano Chavira – 00:01:12:

Oh, thank you so much for having me.

 

Dr. Rebecca Dekker – 00:01:14:

Yeah, we’re so excited to get your perspective as a physician and maternal fetal medicine specialist on breech birth. We’ve been talking a lot about breech recently. And I was wondering if you could start off by just sharing with our listeners a little bit about your background and experience as an OB who is skilled in attending vaginal breech births.

 

Dr. Emiliano Chavira – 00:01:34:

Yeah, I could probably break that up into two phases. Before the breech birth phase of my career and then the after breech birth. So when I was a resident, I was not trained in breech vaginal birth. And in fact, I don’t really recall witnessing a single breech vaginal birth. What’s fascinating to me about that is, you’ve gone over the term breech trial in prior presentations, which was published in about the year 2000. And in many ways, this study was like the death knell for breech vaginal birth. And I started my residency in 2001. That was when I was an intern in OB/GYN. And already one year later, there was not one single breech vaginal birth. And this is, you know, at a major medical center in a major metropolitan city in the United States, which is, you know, Los Angeles. I just think it’s very remarkable to reflect on that, you know, how quickly, breech just disappeared from the landscape. But it was never part of my training. I did my four-year OB/GYN residency. And then following that, I did a three-year training program in maternal fetal medicine, which is a high-risk pregnancy, and that’s not so much about birth as it is about, you know, medical complications of pregnancy, which, you know, maybe various illnesses that the mother carries, or maybe it’s problems that the baby has, you know, birth defects or other issues. So there wasn’t really a lot of birth training as part of the, you know, maternal fetal medicine fellowship. And after I completed my training, I, you know, set out to practice. And, you know, one of the things about my practice as a maternal fetal medicine specialist that I think is a little bit unique is that I have always continued practicing obstetrics, meaning, you know, childbirth, vaginal birth, C-section, and so forth, working on labor and delivery. And I would say probably the majority of maternal fetal medicine specialists don’t do that. They just kind of do the ultrasounds and the consults and so forth. But I’ve always been on labor and delivery. I’ve always… continued to practice obstetrics. And there came a certain point in time where I looked around, And I saw that women that were carrying a breech baby really had no option for vaginal birth. And essentially they’re put in a situation where they are forced to undergo surgery. And that’s whether they want the surgery or not. That’s whether the surgery really is to their benefit or not. It just doesn’t matter. They’re forced to have a surgery. And this is essentially universal. And I just came to perceive that that was not a good place to be for our specialty where you’ve got this population of moms that we cannot offer them a safe vaginal birth. We have to force them into Cesarean section one way or another. And I just decided that was an untenable, terrible place for us to be as a profession. So… I sought out training in how to attend these births. And that story maybe is for another time. The second phase of my career in which I have been attending breech vaginal births. It’s remarkable how challenging that has been. You would think perhaps, naively, that if you bring a special skill to the table, that that will be appreciated, that you might be held in high esteem by your peers. Oh, wow, this colleague of ours has this special skill and this special training that we don’t have. What a wonderful asset to our department. But in fact, that is not what happens or that is rarely what happens in modern OB/GYN departments, modern hospital-based labor and delivery units. What really happens is they are very concerned that you are bringing a lot of liability to the department and to the hospital, and they really want to stop the practice. There’s a lot of external pressure put on you. There’s a lot of harassment and bullying. My friends across the country who are also breech providers have all gone through these things where the department tries to ban the process of vaginal birth or take the privileges of the provider away so that provider is no longer able to work in that hospital. It’s really a constant struggle and a constant battle. It’s been kind of a game of musical hospitals. Where you practice at one place for a while until eventually they figure out how to shut it down or ban it. And then you move to another hospital and you practice there for a while. And then eventually they shut it down and ban it. And you move to another hospital and it’s sort of just, you know, on and on and on. So it’s really been a struggle to offer the service in the modern maternity care environment.

 

Dr. Rebecca Dekker – 00:07:05:

When you talk about bans on breech vaginal birth, do you mean that there’s actually a written ban, like a new policy that it’s not permitted and anybody who has a breech baby must undergo a C-section? Or is it more of like a de facto ban where they just take away your privileges to practice there if you do it?

 

Dr. Emiliano Chavira – 00:07:25:

It’s usually not a written policy. Usually what happens is a person in a position of high power will express that… that it’s not permitted. A lot of the pressure went through the nursing staff and the nurses were instructed that breech vaginal birth is not to happen at this particular hospital. So now all of a sudden, the nursing staff is very uncomfortable, you know, attending these types of births because they’re being instructed that, you know, it can’t be done. And so even though it’s not a written policy, it does become sort of a de facto policy. You know, taking care of pregnant people giving birth is really a team effort. You know, you need the help of everybody. You need the help of the lab. You need the help of nursing. You need the help of the anesthesiology service, the pediatrics. You can’t do it sort of as a lone wolf. You really have to have, you know, buy-in from the whole structure. I’ve always wondered whether it’s legal to do this. You are stating that a pregnant person cannot walk into the hospital carrying a breech baby. And refuse a C-section. And if she doesn’t want to do that, then she’s not allowed to walk through the doors of the hospital. But perhaps they know that it’s legally dicey to try to put these kinds of restrictions. And so they just do it verbally.

 

Dr. Rebecca Dekker – 00:08:47:

Oh, I see. That’s why it’s not written because they know it probably wouldn’t hold up.

 

Dr. Emiliano Chavira – 00:08:52:

Maybe. I wonder. I wonder about that.

 

Dr. Rebecca Dekker – 00:08:55:

It’s interesting because it sounds almost like you have a network then. You communicate with other providers around the country. Just off the top of your head, can you guess how many obstetricians you personally know who deliver breech babies vaginally? Is it like, you know, a handful or a couple dozen?

 

Dr. Emiliano Chavira – 00:09:12:

Yeah, I mean, without counting, it’s probably around 10 or so that I know of. Maybe a little more. There are probably others that I haven’t met. It does tend to be kind of a small, closely knit community.

 

Dr. Rebecca Dekker – 00:09:29:

And they tend not to advertise what they do, correct? Because they don’t want to draw scrutiny.

 

Dr. Emiliano Chavira – 00:09:35:

Yeah, I think it’s just sort of, it kind of gets around by word of mouth. And I don’t know of anybody who… you know, openly advertises this service, but people tend to find out, the community tends to find out.

 

Dr. Rebecca Dekker – 00:09:48:

So if someone was referred to you, perhaps by a doula or a midwife, How would you assess the situation to determine if someone’s a good candidate for a vaginal breech birth? Because it’s my understanding that not everybody is the best candidate. And what are some factors that influence kind of your discussion with the client?

 

Dr. Emiliano Chavira – 00:10:11:

It’s interesting that you say if a doula or a midwife refers somebody to me because they’re the only people that ever refer anybody to me. OBs in the community do not. Because they don’t want to have anything to do with breech vaginal birth. They really just want to deliver these babies by Cesarean section. The reality is that almost everybody is a candidate. I mean, to summarize it simply, you basically have to have a normal pregnancy. You know, there’s nothing obstructing the birth canal, like, you know, giant fibroid tumors or placenta previa. So, you know, vaginal birth is possible. There’s going to be no… major anomalies that could potentially complicate childbirth, especially anomalies that are associated with a big mass. I think that probably makes intuitive sense. If the baby has a big tumor coming off of it, it might be most safely delivered by a Cesarean section. Generally, we’re talking about term pregnancies with babies of normal size. Normal size is a pretty broad range. There’s a lot of conversation about what type of breech, what most breech providers would say is the baby should either be what’s called frank breech, meaning the baby is folded in half and the feet are up by the face. Or complete breech, where the knees are bent and so the feet are down by the baby’s rump. Many people would say that what would be an exclusionary finding would be if the baby’s footling. Footling is a very interesting topic because as it turns out, it’s really very poorly defined in the medical literature and from one country to another and over different time periods. And there’s very little data, assessing what the outcomes are in a footling breech. I think what happens very often is you have a baby that’s a complete breech, meaning the knees are bent, so the feet are down by the butt, and you may actually be able to feel the feet as you’re doing a cervical exam, Or the feet may actually exit the vagina before any other body part of the baby and that may be incorrectly labeled as a footling. It’s probably the case that footling is actually very hard to happen in a term baby. This is probably something that you’re either gonna see in a real preterm situation, or maybe in a twin pregnancy where the second baby is a breech. You might see a footling there, but in general, I would consider that to be a very rare occurrence at term. So almost everybody is gonna be a candidate for breech vaginal birth, just like, if you have a pregnancy with a head first baby, you know, the vast majority are candidates for vaginal birth.

 

Dr. Rebecca Dekker – 00:13:14:

Okay, that sounds good. And when you talk about variations in size. I know it’s difficult to determine a baby size, but if you’re really worried about growth restriction or on the other hand, if you have somebody with diabetes and the baby’s measuring really large, those might be reasons not to do a vaginal breech birth.

 

Dr. Emiliano Chavira – 00:13:32:

Or to consider that cautiously. One of the most interesting breech birth studies for me is the PREMODA study. And this particular study, which looked at several thousand breech births, did not find any difference in outcomes between vaginal birth versus C-section. So there was no benefit to C-section observed in this particular study. And one of the things that’s interesting about this study compared to others is they really outlined in detail what the criteria were for breech vaginal birth. And so the estimated fetal weight was somewhere between two and a half kilos and four kilos. You might consider that some kind of, you know, like a reasonable range. On the other hand, you know, you always have to individualize things. You know, if you… you have a mom who’s given birth to an 11 pound baby before, you would take that history into account, right, when thinking about the safety of the childbirth. I always think of those guidelines as being sort of a general framework, but then you always have to individualize to the specific case that’s before you.

 

Dr. Rebecca Dekker – 00:14:44:

Okay. Another question I have for you, Dr. Chavira, is about physiological birth, meaning unmedicated birth where the birth unfolds without intervention. It was really fascinating to me. I went to the Breech Without Borders training a few years ago, and they talked about how most OBs who were trained in breech, kind of the old guard, people who are very few of them left, but the ones who still held the skills were trained that, you know, it was a medicated birth. The patient’s on their back in the lithotomy position and forceps are used to extract the breech baby. And then at the training, they were talking about how there’s a, I don’t want to say it’s new because it’s not necessarily new. Midwives have been doing it for a long time, but that now a preferred method is a physiological breech vaginal birth where it’s an upright birth, if at all possible. The birthing person is not medicated so that they can move around and assist in different ways. And you don’t use forceps unless there’s some kind of emergency. Can you talk a little bit about the difference between those two? Like which one were you trained in? Which one do you prefer? And, you know, does the physiological birth seem to be easier or not?

 

Dr. Emiliano Chavira – 00:15:56:

Yeah, so I’ve been trained in both, you know, with moms in a supine position, which is, you know, essentially laying on their back. And then this more physiologic approach where mom is maybe on hands and knees or a little more upright. And actually, I think it’s important to have experience with both because labor’s a little unpredictable. You never know what position everybody’s going to find themselves in. And I think it’s good to have access to maneuvers, you know, irrespective of what position the birthing person is in. So I think it’s good to have all those skills and be ready for anything. The upright or the physiologic approach that you’re describing, I mean, you’re absolutely correct. It is not new, but I think what is new is that there are now centers that are really looking at this approach and trying to… apply the principles of evidence-based medicine to it and actually study, you know, outcomes. There’s so much of what is done in the practice of medicine in general and in obstetrics, which is really just kind of tradition and, you know, what you were taught and maybe not necessarily subjected to any particular kind of studies or experiments to see what stuff actually works and leads to good outcomes. Versus stuff that is just what you’ve been taught, so it’s what you do. So there are centers where they actually, you know, try to compare outcomes with these different approaches, particularly Frankfurt Germany, has been one very active center, putting out a lot of studies. And they’ve actually done a comparison of the on the back versus the upright position. There’s a limitation in the sense that this is not a prospective or randomized study, it’s more retrospective and observational. So that creates some limitations. But what they did see was that labor tends to be a little bit faster in the upright position. You have lower rate of injuries to both mom and baby. And there’s also lower utilization of maneuvers to help the baby through the birth canal. So there is some evidence emerging that that’s probably a better position for a breech birth. And in fact, it may be that this is a better position for all births, but generally moms are put in the lithotomy position because that’s just sort of you know, the way it’s been done for all these years. There was another study where they did an MRI study and they put moms into an MRI machine in different positions and found that when moms were flipped over and not on their backs, but more on the hands and knees, that the pelvic diameter is opened up by as much as a couple of centimeters. So it created a little more… room which, you know, I think that it just sorts of adds to why it makes sense that that would be a better, you know, birthing position, not only for breech babies, but probably for all babies.

 

Dr. Rebecca Dekker – 00:19:09:

Exactly, yeah. We’ve talked a lot about the evidence on upright birth, and you’re right. I hadn’t really thought about the fact that upright positions are helpful for a vaginal birth in general. So it would make sense it’s also helpful to… In both cephalic head first and breech births. And when I was at the training, I was surprised to see some of the videos that they showed. A lot of them were using the hands and knees position that you described. Can you tell our listeners a little bit about what the provider does as the baby is coming out in a physiological breech vaginal birth where the birthing person’s in an upright position. What do you do with your hands? Like, what are you doing while it’s happening?

 

Dr. Emiliano Chavira – 00:19:51:

Yeah. It’s a really fascinating experience because one of the differences between a breech birth and a cephalic birth, is that with a cephalic birth, as the birth is occurring, the baby’s really still inside the mother’s body. All you see is kind of the tip of the head, you know, as the baby’s crowning. And then all of a sudden the head is out and the body follows. And it all happens within a few moments. That tends to be a very fast procedure. But with a breech birth, the body comes out first. And then the head follows last. And so you actually, physically watch the baby during the birth through most of the process. And so you see the rump emerging and the feet emerging and the body and the arms and the head, and you’re watching it all. What the duty of the… the birth attendant is… is to observe the birth happening and discern whether things are happening normally and you don’t need to do anything. You can just let the birth happen because it’s happening in an appropriate timeframe and the baby is doing all the appropriate movements that it needs to do to pass itself through the birth canal. And it’s incredible to see how active babies are in their own birth, the birth process. It’s really been kind of mind blowing to learn about this and to witness this in a way that you don’t really get with a cephalic birth. Because you can’t really see the baby doing what it does in a cephalic birth, but you can see it happening in a breech birth. And so you’re watching and making sure that the baby’s doing the appropriate movements. And also you have some ability to assess the condition of the baby. So if everything is happening in a reasonable timeframe and the baby appears to be in good condition and the baby’s doing all the appropriate movements and progress is happening, you basically do nothing. You sit there and watch.

 

Dr. Rebecca Dekker – 00:21:55:

You don’t touch the baby or anything?

 

Dr. Emiliano Chavira – 00:21:58:

Yeah, there’s a lot of discussion about hands-off and the importance of hands-off. And I don’t know that there’s any evidence-based reason why it would be harmful to touch a baby, but it’s just not needed. If it’s not needed, it’s not needed. But at the same time, there’s a pretty substantial percentage of these births where the baby has difficulty passing through the birth canal and may not do the normal movements that it’s supposed to do. Sometimes, you know, the arms can be up. Maybe even behind the head or behind the neck or just in weird positions that make the birth more difficult. If it’s a very long, slow birth process, particularly if you’re having some cord compression, during the birth process, the baby may not be, you know, getting adequate oxygen delivery during those minutes. And some of these babies start to lose tone. In other words, they kind of start to go limp. And in that situation, the baby’s no longer helping itself. It becomes much more passive, right? And requires either the mom to push the baby out or the birth attendant to help the baby out. You’re basically watching for those things. So if things are maybe taking a little too long, you might decide to assist. If the baby’s not doing appropriate movements, you may decide to assist. And you’re basically trying to reconstitute the normal movements through the birth canal. So if the baby’s not doing it, on its own, then you try to help those normal movements happen. And some of this involves rotational maneuvers where you rotate the baby around to help dislodge the arms. Some of these movements are to help the baby flex its head, which helps the head come out of the birth canal. So there’s different movements. But basically, your responsibility as a birth attendant is to know when you’re witnessing a normal birth that you don’t need to intervene. Or when you’re watching a birth, that is starting to deviate from normal and so you have to decide when is an appropriate time to do an intervention and also have the knowledge about what the appropriate interventions are. That’s critical to making the breech birth generally safe with the very low risk of bad outcomes. You’re never going to have zero risk of bad outcomes.

 

Dr. Rebecca Dekker – 00:24:35:

I think the thing that really puts families between a rock and a hard place is the fact that, you know, you can, most people can have a breech vaginal birth. But if there’s no skilled, trained attendants who know what normal breech birth looks like and what to do, like what is abnormal and which specific movements do you do? If there’s, like you said, a deviation from normal, then that’s where it could get scary really quick if the providers don’t know, have a clue what to do.

 

Dr. Emiliano Chavira – 00:25:06:

Yeah, and in fact, generally, you know, when I have counseling sessions with people who are considering a breech vaginal birth, one of the things that I say is, this is really a safe endeavor if you have an experienced person that knows what they’re doing. If you don’t, I think the risk goes up substantially. And in that kind of scenario, I think the Cesarean section is the safest way to go. So, you know, I say to them, while we’re planning this, if something down the line happens, you find yourself in some hospital and there’s no breech provider there, I would recommend accepting the C-section as the safest way to go. Obviously, people have the right to decide whatever they want to decide, but that’s what I would recommend.

 

Dr. Rebecca Dekker – 00:25:55:

You mentioned cord compression and maybe the second stage, the pushing phase, taking too long. What are some other complications that can arise during a breech birth and how do you manage them?

 

Dr. Emiliano Chavira – 00:26:10:

You can have things happen in a breech labor that can happen in a cephalic labor. So you can have infectious complications during labor, you know, like where a mom’s starting to get a fever and you know, you’re starting to see clinical signs of that, fast heart rates and so forth. And, you know, generally we manage that with antibiotics in labor. Potentially antibiotics postpartum. Depending, and so that management would be the same. Sometimes you can have… protracted labor or stalled labor. In a cephalic birth, generally we would manage that by either continuing to wait and allow more time to pass, or maybe even stimulating labor with oxytocin. Whether that’s appropriate to do with a breech birth I think it’s somewhat controversial. There’s some conventional wisdom or should I call it lore, among breech birth providers that one of the things you want to see is an efficient rapid birth. I’m sorry, labor. And that’s a signal that you’re heading toward a successful vaginal birth. And obstructed or stalled labor, maybe that’s a warning sign. You know, from an evidence based point of view, I don’t know that I’ve ever found any studies actually looking at that to confirm that. You know, if you have a longer labor or if you’ve sort of fallen off the traditional labor curves, is that a higher risk birth? I don’t know that I’ve seen any studies that confirm that.

 

Dr. Rebecca Dekker – 00:27:48:

Yeah, the only one I saw was a study by, a report by Fischbein and Freeze looking at a cohort of babies born breech vaginally, and they mentioned that the several parents that they sent to the hospital for Pitocin who chose Pitocin and a vaginal breech delivery at the hospital ended up having extremely difficult births. And so their thought was, you know, maybe it’s preferable if you’re, for example, if you’re having a home breech vaginal birth and you’re transferring, or if you’re having a breech vaginal birth in the hospital and you have this completely stalled out labor, that a C-section might be preferable than trying to do an extremely difficult vaginal breech extraction.

 

Dr. Emiliano Chavira – 00:28:31:

Yeah, the only problem there is that that’s like two cases. So essentially, that’s anecdotal. That’s true. That’s anecdotal data. And there are case series published of induced labor with breech pregnancies. And if you pull them all and add them all up, it adds up to about a thousand births, and what’s generally reported in these studies is comparable outcomes to cephalic inductions. So there doesn’t appear to be a signal that inducing labor is more dangerous in a breech pregnancy than a cephalic pregnancy. The problem there though is that’s an induced labor, which is one population of people. If people having a stalled labor is a different population of people. And so whether the evidence applies to this particular category of people, I don’t know that we have good evidence on that.

 

Dr. Rebecca Dekker – 00:29:33:

Speaking of evidence, I know we have really good evidence that external cephalic version can be a good choice for families with a breech baby who, for whatever reason, don’t want to or can’t attempt a breech vaginal birth, but they want a vaginal birth so they can try and get the baby into a head first position. We cover that in episode 173, but I was wondering if you could talk a little bit from your personal experience as an OB and MFM, do you feel like most OBs in the US are comfortable with and skilled and offering ECV?

 

Dr. Emiliano Chavira – 00:30:08:

Absolutely not. Generally, in the different locations that I practiced. It’s been a minority of physicians that that offer and practice ECV. In some settings, it’s because you may have a group practice and there are one or two people that are the ECV people and so the other practitioners in the practice just don’t really have any need to do it. They may not have any opposition to it. They may be perfectly in favor of it, but there’s somebody in their practice that does it. And I think that’s fine. So I’ve encountered that. But then in some community centers where, you know, you have thousands and thousands of patients that are all going to their individual, you know, separate communities and providers, you very often find that almost nobody does ECV. You know, one particular community I work in in South LA, there’s really no other providers. I’m the only one that does it. And I get a lot of referrals from the community, from doulas and midwives and chiropractors. There are one or two OBs in my community that will send their moms to me for ECV. But the large majority don’t. For most modern OBs, I think breech equals C-section, and it’s just as simple as that. And there are no other options and there’s no other discussion. I had an experience once where I offered an ECV to a mom who had been referred to me for some other medical problem, maybe it was diabetes. But I offered the mom an ECV and later, the supervising physician from that clinic expressed being very upset. That I had done this. And the reason was, what they explained to me was, well, you know, even if you do the ECV, if something bad happens, I get dragged into the whole thing. So they’re, this was an expression of pretty intense medical legal anxiety. Even if they’re not the one doing the procedures. So they don’t even want to refer to a different provider because they just don’t want to open that can of worms. So generally, very few OBs offer and practice ECV. Most of the moms that I have… you know, run into… a large majority of them, they were never offered ECV or if they brought it up with the provider, the provider had all kinds of reasons why it wasn’t a good idea. When probably the reality is it probably just doesn’t do it and they just want to schedule the C-section.

 

Dr. Rebecca Dekker – 00:32:55:

That makes sense. And if it’s not something that their clinic offers among their group of OBs, they’re probably reluctant to refer to a completely different practice for many reasons that the legal liability being one of them. Do you feel like ECV is something that most residents get trained in? Are they required to, for example, like watch videos, practice on models? Do they have to do a certain number before they can finish residency or is it not required?

 

Dr. Emiliano Chavira – 00:33:24:

Yeah. So when I think about the types of cases that we had to log and get a certain number, ECV was not on that list. Definitely in my residency, it was a standard procedure that… you know, when a patient was carrying a breech baby a term, they were offered an ECV universally. And when you were on your OB/GYNs rotation, if one came up, you did it. So I think we were all trained. I couldn’t necessarily speak to other residency programs. I mean, I know some people are being a trained because ECVs are happening across the country. Maybe it’s more like academic centers than community centers. There’s probably a smattering of community physicians here and there who do it. But by and large, I think, It’s not offered to the extent it’s supposed to be. If you look at American College of OB/GYNs guidelines, they basically say this should be offered to all, all pregnant people carrying a breech baby at term, assuming vaginal birth is an option, right? You don’t have a previa or something like that.

 

Dr. Rebecca Dekker – 00:34:35:

Yeah, it’s fascinating to me the difficulties that it puts providers into, like you, who want to offer more options, but perhaps it’s not supported in your community or you find pushback. So, you know, we talk a lot about parents who find themselves pregnant near term or at term with a breech baby or often between a rock and a hard place if they want more than one choice because they’re often only presented one choice, which isn’t really a choice if you’re not given something else as an option. So when you meet parents like that who are close to term, what advice would you have for our listeners? So if somebody’s finding this episode, and I know you’re not giving medical advice, but what would you typically say to someone that finds themselves in this position? Some words of encouragement or support?

 

Dr. Emiliano Chavira – 00:35:24:

Yeah. Well, once they get to me, they’ve already gone through a search process. And then basically at that point, I just give them evidence-based counseling. We talk about their options. Sometimes we do run into the barrier that they may be from far away and their insurance may not cover services at the hospital where I work. So there can be financial barriers, but at least they’re getting accurate, high quality information. So I think for families that find themselves at the beginning of this journey, generally the scenario is gonna be your approaching term, the baby’s in a breech presentation, and the OB/GYNs is starting to talk about scheduling the C-section without any discussion of any other options. The first thing I would say is in the 34 to 37 week window, prior to 34 weeks, honestly, I wouldn’t worry about a breech-presenting baby. I don’t think you need to stress about it, and you don’t need to do anything about it. But as you get into this 34 to 37 week window, if you wanted to get a little more proactive, I would look at the Spinning Babies website. And think about maybe doing some of those inversion exercises. Some people work with chiropractors or other body workers. That’s a 34 to 37-week window. 37 weeks is generally when we would think about moving on to the ECV if baby is still breech at that point in time. So as you’re approaching that window, I would say you want to ask the OB. You know, this can be challenging because if the OB  has not spontaneously brought it up there’s probably a reason for that. Maybe they don’t have experience with it or haven’t done it or have done very few or whatever the case may be. You can potentially ask if your provider knows of someone in the community that has experience with ECV that they could refer you to. If you find yourself getting no help from the provider, which very often is the case, then you may just need to, you know, try to search through other channels, maybe through, you know, a group like Breech Without Borders that, trying to assemble a a catalog of breech providers around the country and see if you can find through your own investigations you know like local resources. And then after that, if it gets to breech vaginal birth, you can ask your provider about it. And what I’ve generally heard from moms that I interact with is when that question is asked to the OB/GYNs provider, the answer is usually absolutely not. I think what is generally not going to happen is, is, uh, obstetricians do not view that as a scenario in which this patient needs to be referred to a specialist. In other areas of medicine, that’s… automatic, right? Like if you have a cardiac problem, you get referred to a cardiologist. If you have a cancer, you get referred to the oncologist. Or even pregnancy-specific complications of a high-risk pregnancy, they will refer you to a high-risk pregnancy specialist. Even in the high-risk pregnancy specialist, if you need a fetal surgery, they may refer you to the super specialist that does the fetal surgery. We’re used to referring people who need services to other providers that offer those services. But for some reason, breech is not treated that way. And so they’re usually not going to refer you to somebody in the community who does breech birth. For some of the reasons we talked about before. They just don’t want to have anything to do with that. And they want to deliver you by Cesarean section, which they feel is the safest way of managing the scenario. And they don’t really want to think about other options. So you may have to do this search on your own. And, you know, look through other channels.

 

Dr. Rebecca Dekker – 00:39:33:

If that’s what you want. If you want to explore that.

 

Dr. Emiliano Chavira – 00:39:36:

If that’s what you want. And I will add that, you know, if that’s not something you’re interested in and you feel safest being delivered by Cesarean section, I think that’s absolutely a perfectly reasonable and acceptable decision, you know. You know, that study that I mentioned before, the PREMODA study, it was something like 8,000 breech pregnancies. And this study was conducted in a country where breech vaginal birth is normal. It’s readily accessible. Anybody who can do it, you know, anybody who wants to do it, they can do it. This country, they reported outcomes that were equivalent between vaginal birth and C-section. And even in that scenario where women had really free choice to decide. More than 5,000 of them chose Cesarean section. So, you know, that’s a perfectly reasonable choice And, and, and, and, uh, I don’t want anyone to interpret this as you should have a vaginal birth. I think what you should have is you should have the choice. But if your choice is Cesarean section, that’s fine.

 

Dr. Rebecca Dekker – 00:40:44:

And going back to the PREMODA study, which I talked a little bit about in episode 296. There was no difference, like you said, in mortality and the overall outcome of morbidity, but some of the individual outcomes were different and favored the Cesarean group. So like you said, it’s a good choice if that’s your choice. The problem is people aren’t given a choice is more what we’re talking about. And I think that’s really hard. I would love to hear, Dr. Chavira, if you see any future trends or developments in this field that you’re a specialist in. In terms of caring for breech pregnancies or breech delivery or anything like that?

 

Dr. Emiliano Chavira – 00:41:34:

Yeah. You know, in 2016, I went to the Amsterdam breech conference. And one of the presenters was a German doctor from Frankfurt. This is Dr. Louwen, and he made a comment that really stuck with me. And he said that, he said, you know, obstetricians very often ask the most uninteresting questions. You know, they debate up and down and left and right ad nauseam, which is safer, you know, breech vaginal birth or Cesarean? I said, that is an entirely uninteresting question. Because the reality is, both are always going to exist and both are necessary. And the real question is, how do you make each safer? How do you make the Cesarean section safer? And we should devote our energies to answering that question. And by the same token, how do we make vaginal breech birth safer? What are the best techniques? What are the best approaches? And that’s really the interesting question. Even as we exist in this era, where you know, many obstetricians have wholesale abandoned breech vaginal birth. You have in certain places around the world a resurgence in interest, but also active, ongoing research to try to answer previously unanswered questions so that we can refine our techniques, make it safer and safer over time. So I find that exciting. There’s also this organization which I mentioned previously, Breech Without Borders. They’re traveling around the world, actively teaching breech techniques to anybody who wants to learn them. Currently, that means it’s mostly midwives. Mostly attended by midwives, but you see some obstetricians here and there. But what’s happening now is… they’re actually running their sessions with some OB departments. So I think you’re starting to see a little bit more uptake. You know, it’s very incremental, but that’s moving in the right direction. I don’t foresee us getting back to a place where breech vaginal birth is a standard obstetric maneuver that all OBs practice. But what I would love to see would be if it came to be considered a standard specialty that some OBs have. And in every community, there’s somebody who enjoys the challenge of attending breech vaginal birth and who becomes experienced at it and who becomes good at it. Such that, you know, in families where they have a breech presenting baby, there’s somewhere to send them instead of having to force them into an unwanted Cesarean section. So if this became something that you had one person in every OB department, I think that would be… so much better than what we have now.

 

Dr. Rebecca Dekker – 00:44:54:

Right. We would just need all the hospital administrators and lawyers to get on board with that approach of treating it like a specialty rather than…

 

Dr. Emiliano Chavira – 00:45:04:

Yeah, they need to be protected and supported as opposed to what happens now if they’re—I’m out to dry and run out of town.

 

Dr. Rebecca Dekker – 00:45:14:

Yeah, it’s a big issue. Dr. Chavira, thank you so much for coming on the podcast to share your knowledge and wisdom with us, and thank you for everything you’re doing to support families in California. Is there anything else you’d like to share or anything else you want us to know about?

 

Dr. Emiliano Chavira – 00:45:32:

Yeah, the one other thing that I would mention that’s always important for us to think about is the issue of justice, disparities in outcomes that we see in our country, depending on socioeconomic status, depending on race, things like that. And one of the things I have experienced is a lot of women will come from fairly large distances to come have a breech birth with me. But that tells you right away that they have the resources to find me in the first place, to make the travel arrangements, and so on and so forth. And these are options that women of low income and very often that follows, you know, race-based lines. May not have these options open to them. So again, if you’re a poor woman of color in the inner city and breech birth is not an option in your hospital, then it’s just not an option and you get forced into a Cesarean section. Whereas women of wealth and greater means can sometimes find options that are out there that other women can’t.

 

Dr. Rebecca Dekker – 00:47:01:

I think that’s a good reminder that that needs to be, you know, something that we’re constantly working on and bringing light to as well. And also with the training as well, you know. Making sure that these trainings are provided and led by communities of color rather than mainly staying in the hands of, of white midwives and birth workers. So thank you so much for bringing that up. Dr. Chavira, is there any way that people can follow you online?

 

Dr. Emiliano Chavira – 00:47:32:

Yeah, I’m pretty old. So that means I’m not super savvy about social media things and my online presence is pretty meager. But the one place would be Facebook. I have a Facebook page. And it’s basically my name, Emiliano Chavira, MD, MPH, FACOG. Those are all my… my various degrees and so forth.

 

Dr. Rebecca Dekker – 00:48:06:

And I saw that you had a couple episodes on Dr. Berlin’s podcast, the Informed Pregnancy podcast. So we’ll put the link in the show notes to get those because those are different topics that you talked about that were also really interesting. So thank you, Dr. Chavira, for coming on today. We appreciate you.

 

Dr. Emiliano Chavira – 00:48:23:

Oh, thanks for having me. It was a lot of fun.

 

Dr. Rebecca Dekker – 00:48:25:

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