September 16, 2015

One evening in June, Dr. Elliot Berlin, a Los Angeles-based prenatal chiropractor, childbirth educator and labor doula, posed for pictures on a red carpet in Burbank. Flashbulbs sparkled and Berlin, sporting a yarmulke, posed before an impressive turnout of celebrities, physicians, and parents with their newborns and toddlers, including one mother wearing a “Boobie Palooza” shirt from a 2011 festival Berlin created to inform women on the benefits of breastfeeding.

This was the unveiling of Berlin’s newest project, a documentary titled “Heads Up: The Disappearing  Art of Vaginal Breech Delivery.” The film, as evidenced by the title, raises the issue of how doctors deliver breech presentations — when a baby in a mother’s womb is in a head-up position at the time of birth.

Berlin is easily the tallest person in the room, exuding a gentle-giant persona. His shoulders hunch slightly in a way that makes him seem to be apologizing for his burly silhouette. 

“I’m a maker of babies, and most recently, I’m a maker of films about making babies,” Berlin, 41, announced to the theater’s packed audience. Laughter and applause ensued.

Offering thanks to the film’s producer, Melissa Kennedy, Berlin, a father of four, spoke to the audience about the documentary in a sentimental tone overlaid with no shortage of birthing puns.

Later that night, one of Berlin’s former patients, who was featured in the documentary, said of the chiropractor, “I think of Mr. B. as my Jewish fairy godmother!” Although Berlin isn’t an obstetrician, he’s the middleman between expectant mothers and their physicians.

“Heads Up” is a candid snapshot of the current debate surrounding breech births and chronicles the expertise of Berlin, three local doctors (Stuart Fischbein, Paul Crane and Ronald Wu) and a handful of mothers who’ve had breech babies, including “Homeland” star Morena Baccarin and holistic personality Kimberly Van Der Beek (wife of “Dawson’s Creek” actor James Van Der Beek).

In a phone interview just days after the premiere, Berlin posed a simple question to a reporter — the same question that drove him to make this movie: How do we restore a woman’s choice?

The 30-minute documentary begins with a stick-figure illustration. 

“Human pregnancy lasts about nine months,” the narrator says as a pregnant figurine walks onto screen.

“In the final eight weeks, in preparation for delivery, most babies will settle into a head-down position,” the narrator says as an illustration of stick figure babies flip upside down in their mothers’ wombs.

“About 4 percent of those babies will not get head-down,” the narrator continues. The statistic may seem small, but Van Der Beek makes sure to mention later in the documentary, “This is somewhat more common than me having red hair,” she says, swinging her long ginger mane.

Breech happens when either the umbilical cord is too short, the uterus is heart-shaped — or maybe the baby just didn’t get the memo. Regardless of the cause, such pregnancies are called “breech presentations.” 

In fact, Berlin was a breech baby (about which, his mother, who flew in from New York for the premiere, told the Journal with a nudge and a wink, “As they say, it all starts in the womb!”).

Pregnancies with babies in breech presentation are considered high-risk because of the risk of fetal death during natural delivery. 

“Up until the year 2000, a woman carrying a breech baby had two choices. She could have a vaginal breech delivery or a Caesarean breech delivery,” the film’s narrator says, adding, “in 2001, one of those options disappeared almost entirely.”

In October 2000, a study dubbed “Term Breech Trial” was published in the British medical journal The Lancet. The article would forever change the field of obstetrics. 

Spearheaded by a Canadian obstetrician, Mary Hannah, it was the largest randomized controlled study ever performed in the field of breech, conducted in 26 countries with more than 2,000 women over the period of a year. The prognosis of the study was firm: “Planned Caesarean section is better than planned vaginal birth for the term fetus in the breech presentation.” 

In 2001, the American Congress of Obstetricians and Gynecologists (ACOG) officially voiced its stance on the matter in a published “Committee Opinion,” siding with the Term Breech Trial and recommending against natural deliveries of breech babies. Practically overnight, obstetric schools stopped teaching medical students the procedures of breech delivery, and hospitals banned the practice. 

Caesareans became the status quo in breech presentations. Now, more than 80 percent of all breech pregnancies are delivered via C-section.

Fischbein, a local obstetrician who used to be a resident at Cedars-Sinai Medical Center, told the Journal the stigma surrounding delivering natural breech births ultimately led him to start a private practice. Currently, he is the only OB-GYN in Los Angeles who performs natural breech deliveries in a woman’s home.

“Nobody is trained in the practice of breech, so nobody feels comfortable with the practice,” Fischbein said. 

The same stigma that led Fischbein to embrace a private practice is what led expectant mother Rebekah Park, a patient of Berlin’s, to keep her decision to have a breech birth under wraps. Although Park was a perfect candidate for a natural breech delivery (fitting criteria that included the shape of her pelvis, the size and position of her fetus and the right mental attitude), she was advised by her first doctor that a Caesarean would be her best option, and she was discouraged from pursuing a natural delivery. 

Three doctors later, she eventually found Wu (recommended by Berlin), who performs about three breech births a week. Older than 70, Wu is one of the only remaining obstetricians in Los Angeles trained to deliver a breech baby naturally. 

Park said she didn’t feel comfortable discussing her decision of natural breech delivery with anyone outside her immediate family. “There’s a prejudice against breech birth,” she said.

“In the end, he came out a delightful, beautiful child,” she said of her now nearly 4-year-old son, Ezekiel. 

But she said of the experience: “It’s not for the faint-hearted.”

In 2006, an Israeli doctor named Marek Glezerman published a response to the 2000 trial, pointing out reasons it was flawed. Glezerman criticized the trial’s study design, methods and conclusions. He said the study included breeches that had not been planned for, premature deliveries and abnormal congenital pregnancies — cases that severely compromised the trial’s data.

“He re-analyzed all the data from the Term Breech Trial, and he was the first to come out and say, ‘We made a mistake here,’ ” Berlin says of Glezerman’s research in his documentary.

In response to Glezerman, the ACOG published a revision that same year, retracting its initial stance on natural breech births. But by then, the practice was already virtually obsolete.

“This one study changed the culture,” said Dr. Paola Aghajanian, the director of Labor and Delivery at Cedars-Sinai, referring to the Term Breech Trial. “Once the culture changes, there’s a fear amongst folks, and the training deteriorates. It’s hard to go backward and convince people.” 

Of the more than 100 obstetricians that deliver babies at Cedars-Sinai, and Aghajanian said, “I can only think of one who does breech deliveries.” 

She’s referring to Barry Brock, who’s been in practice for more than 40 years.

Brock is very careful about the cases he accepts, which is why he’s performed very few breech deliveries in the past year. He turns most of his breeches through a procedure called external cephalic version (ECV) where the doctor attempts to externally rotate the baby. If ECV is not successful (it has a 50- to 60-percent success rate), then he considers a natural breech birth, if the mother specifically requests it.

He said the reason other obstetricians don’t offer natural breech deliveries is likely either that they don’t know how to do it, or the liability insurance is prohibitive. 

After the baby’s torso is out, the baby’s head can still become trapped, which can sometimes result in brain damage or death if the obstetrician doesn’t know the correct procedures.

Brock said it’s actually a very simple process, however. “I consider myself a non-panicker,” he said. “We used to do them all the time,” he added.

Aghajanian said, “Would [the medical profession] ever go back to offering vaginal breech deliveries? I don’t think so.”

Berlin, however, is hopeful. 

He believes the best way to reverse the current practice is by opening a regional breech center in Southern California. According to his calculations, if women with breech presentations made the decision to go through with a vaginal breech delivery (and if they fit the criteria), there would be one to two breech deliveries each day at the regional center. 

“With that kind of volume, residents or doctors who have graduated, but don’t have the training, could do shifts there and learn from the doctors who still know how to do a breech delivery confidently and safely,” he said.

Berlin’s suggestion is based on a regional breech center model already finding success in Germany. 

Glezerman, who published the revisionist article in 2006, also was an advocate for regional breech centers in Israel. He even started workshops at the Rabin Medical Center to train obstetricians to deliver breech babies.

In the last three years, however, he’s changed his stance on the matter. When Glezerman speaks, he’s to the point. “I’m disillusioned now,” he said by phone.

Although he still believes that breech delivery training should be included in the obstetric curriculum, “What I have abandoned is the hope that in each hospital, these skills could be available and could be offered,” he said. 

Glezerman now believes training for natural breech deliveries should be taught to be used as a backup in emergency situations.

“Forces are too strong against it,” he said. 

If a woman goes into labor before her scheduled Caesarean, for example, then attempting a breech natural delivery might be unavoidable.

“What happens if she’s in the hospital, and there’s no surgical room available? What happens if the baby is coming out, and nobody knows what to do?” he asked during a Skype session.

To Berlin, a natural breech delivery should not be used as an emergency last resort. Instead, he wants the decision to belong to the women from the very beginning. “If they want a Caesarean or a natural delivery, that’s her choice to make,” he said over the phone. 

“Heads Up” is one way Berlin is hoping to get the word out, by informing expectant families and fellow obstetricians that the choice to have a natural breech delivery should be more accessible.

There’s a video Berlin shows to all of his patients considering a natural breech delivery. It has had more than 2 million views on YouTube, and has reached nearly cult status within the breech community.

It shows one of Berlin’s patients, Sara Lowry, giving birth during a home delivery with her husband, Doug, by her side. Music plays in the background as she goes through the birthing movements. An excerpt from the video appears in “Heads Up.”

What makes this breech delivery so spectacular is the fact that it’s also a home birth, overseen by Fischbein.

In the video, the baby comes out buttocks-first (called “frank,” the most common presentation for a breech delivery). Then one leg, then the other. One arm comes out, then the second. And last, the head. 

It’s a silent delivery. The baby’s head is delivered last, so until the very final moment of labor, when the head finally surfaces, there’s absolute calm. There’s no baby’s wail. No beeping monitor. No signing of paperwork. 

“This is so weird,” Lowry utters in disbelief, just a few moments after giving birth, wrapping her newborn girl, Aurora, in her arms. “I can’t believe it,” she says shaking her head, flushed from the rush of labor.

“This is so weird,” she repeats again moments later, her newborn bundle tucked into her bosom.