Bringing Back Vaginal Breech Birth

Surveillance Medicine: From Hyper Vigilance of Height and Weight to the Friedman Curse and the Attempt to Bridle the Breech

We are developing a short educational video about the history of surveillance medicine. It explores the history of how medicine started in earnest in the 20th century to study healthy populations as an adjunct to the treatment of those who had already succumbed to sickness. We use the example of the measurement of children’s height and weight-- at first of genuine need in poor populations and among the sick, but which became imposed even on healthy well-fed populations. Today the measurement of height and weight is considered an indispensable equation for parents, even though it tells the practitioner little about the genuine health of the child and the parameters developed for caucasians are often imposed on different ethnicities.

In similar fashion, the attempt to define and predict the “normal” in labour came into fashion in the 1950s, when Dr. Emanuel Friedman, of Columbia University, published a study that mapped how long 500 Caucasian women at his centre took to dilate during labour. Plotting progress on a chart of dilation within time frames, a rather coercive behavior was adopted by obstetrics to try to get women’s labours to then conform to this curve. The Friedman curve was based on very interventive obstetrics, including a 55% forceps rate and 13.8% induction and augmentation rate. It was imposed on women for decades even though based on false concepts of "normal."

In answer to the restrictions felt by such interventive obstetrics, women of the counterculture of the 1970s began to have their babies at home. In the early 1990s, following several years of the collection of data of women’s births, principally at home, via the data from the Midwives Alliance of North American database, we plotted the length of time and the plateaus that women experienced during normal labour. This data demonstrated that most primipara did not follow the Friedman curve. Still it took us several decades to undo the damage caused by overly interventive obstetrics.

By 2014 the American College of Obstetrics and Gynecology arrived at similar conclusion and began to suggest plotting dilation only at 6 cm instead of at 3-4.

More recently, as vaginal breech has been re-emerging and studied in earnest, especially from 2004 on, several practitioners have published or presented descriptions of the cardinal movements of the breech and expectations of what might occur as the breech descends and how to intervene or not intervene (Evans 2012; Frye; Louwen et al. 2017; and Daviss 2017). To date these authors have all refrained from imposing time frames on the progress of the breech, in particular on the descent from “rumping” on. Learning lessons from the history of medical surveillance and breech experience in particular, not focussing on timing has been purposeful.

A recent attempt to impose timing (Reitter, Halliday, and Walker 2020) is raising serious concerns among several breech practitioners in the field because of its focus on overly micromanaging the breech and imposing a questionable focus on time instead of on the condition of the mother and the baby. Worse, the time frames in the recent publication are based on a convenience sample of 42 videos taken from the internet and solicitation, with no ability to define the experience of the practitioner attending the births, a full understanding of the interventions used --e.g. oxytocin-- or whether the births were from mothers having their first or 5th baby. Memories of Friedman, which took us decades to undo.

These data are also different from the data of systematic data collections of consecutive births that reveal more ample time allowance for the breech to descend, in particular in the primip (soon to be published). However, we advise not to focus even on these more appropriate timeframes, but on the conditions of the mother and the baby.tion text goes here