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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