It sure seemed like the weekend to have a baby on L&D!
I had three - yep, three! - births on Saturday. Hurray for the babies!!! I had one birth on Sunday, but helped in two others. The baby I cared for yesterday had some trouble with transitioning after the birth, and it was decided that he needed to go to the NICU for the night for closer observation. When I checked up on him a few hours later (I brought mom to the NICU for a visit), he was doing so much better!
We seemed to have a run of primary c-sections for breech presentation. Even on multip mommas. That makes me sad that multips - even those in full blown, active, transitioning labor - get a c-section because they are breech. It just goes to show how much liability concerns come in to play with the OB docs. You would think that a breech baby in a multip (especially when the baby is small, or slightly premature) would slide out like butter, when mom is actively laboring. Isn't it more risky to do a c-section when she is actively laboring, versus a vaginal breech birth?
I have yet to witness a vaginal breech birth in my 9 years as a nurse.
29 comments:
That's crazy! My brother and his wife were both frank breech and both of their mothers managed to get them out without surgery 33 years ago. Their daughter was a frank breech and delivered by c-section this fall. She was teeny (6lbs 3oz) compared to my large-headed 8.5 pound babies -- I joked that her bum couldn't have been any larger than my son's 95th percentile head!
I don't know that liability is the only concern....doing a breech delivery is becoming a lost art. Many docs have never seen or done a breech delivery. It's the same with forceps. We have one doc of three in my practice who will do either of these. We're blessed to have him and have these options.
I've seen several vaginal breeches deliver @ my hospital. However, it seems that they are multips who come in c/c/+something and it all happens very quickly. I have also seen Twin B's deliver vaginally breech--Piper forceps are always at the ready in both cases. It really depends on who the MD on that night is. Mostly our laboring moms get an ASAP section. The true stat c/s for breeches I can remember have ended up in serious complications for mom (serious blood loss) and no chance for VBAC due to extensions. In which case I feel bad for the mom, you know?
I was lucky enough to witness a home breech (compound presentation, foot plastered against/next to rump) of a mama who was trying for a vbac after a breech at 8 cm for a 5 week early first baby!!!
It was awesome, but most awesome of all was how the mama was able to take back her birth, having lost that birth rite with the unwanted c/s with her first!
Thanks to the midwives who were trusting and skilled! A great birth!
My mother delivered our neighbor's breech baby during a snow storm.
When my second child was breech and they did a section, my mother scolded the doctor.
My 5th baby was breech, and we didn't know until I was pushing! I had a planned home birth and was in the birth tub when my midwife discovered his position. He really did slide out like butter, and the transition was so smooth because we were in the water. When his legs were out he was kicking under water, and when his whole body was out other than his head, he actually put his hands and feet on my bottom and helped push his own head out!
He was out within about 10 minutes after we realized he was breech. It helped that I'd had 4 babies before (all in the hospital, 2 of them unmedicated) and knew how to push really effectively, and he was full-term frank breech. He had a dislocated hip, presumably from the birth, that healed up without any medical help other than observation.
I know if I'd been in the hospital with him I would've had a c-section. I'm so glad I had a home birth with a skilled midwife!
I had a C-section because my son was breech. I strongly believe that it was not necessary. I was at 5cm 15 minutes after my water broke without even realizing I was in labor. He was a complete breech, 6 1/2 pounds, and I was dilating like crazy. I would have popped him out like nothing. He ended up under an Oxihood for two days with wet lung from the C/S, as well as having a laceration on his right buttock (funny how the page mentioning the laceration disappeared from my operative report when I got my copy of the records).
I tried to talk about a vaginal birth, but no one would even discuss it. One doctor even walked out of the room when I tried to talk about it.
I am studying to be a certified professional midwife. I fully intend to attend breeches, VBACs, twins, and all those other automatic C-sections that are being pushed these days.
Honestly if my doctor/midwife had never done a breech delivery I would NOT want to be their first! I wouldn't want a rusty doctor either.
Have you ever considered contacting any of the midwives on the Farm? I wonder if they could share with you any information, statistics, videos, etc. about how they attend breech births. I wonder if you could possibly observe on site since vaginal breech births are so rare at your hospital.
BTW, the best "magic trick" I've ever witnessed--at the age of 14--was the external version of my niece, who was a complete breech & twin B. My nephew, twin A, appeared to be a pretty easy vertex delivery. Then, a CNM was successful in a single attempt to turn her. Their births were only 6 min. apart. Beautiful.
I was a vaginal breech birth, and also a 4lb, 3oz 34-weeker. I was born on an ER gurney 10 minutes after my mom got to the hospital (my parents ended up having to drive 90 miles because their local hospital wasn't equipped for preemies -- hence the close call!).
Rixa (Stand and Deliver) has had some postings recently about the return of vaginal breech births, particularly in Canada. The problem is that OBs are no longer trained in it, or seeing them.
But what about external version? Does no one try that when in active labour?
I've seen one. But only because the woman was a homebirth transfer and her awesome midwife advocated for her like crazy, and ultimately saved her from a c-section. It was very intense, but incredible and beautiful too.
In 40 years, I have done 4 vaginal breech births, all multips. And each time my heart was in my throat until the baby was safely delivered. There are SO many risks involved with vaginal breech birth! Whenever I hear a story about a successful one, especially when it is held up as a "you see, there is no need for a nasty old C-Section; just unnecessary medical intervention" I know the person telling the story has no idea of the real risks involved. Who in their right mind would choose to gamble on a crippled, brain-damaged, or dead baby in order to avoid the C/S that could prevent all this? Dislocated hip, brachial palsy, trapped head, spinal cord injury, cerebral hemorrhage, fetal asphyxiation -- these are some of the risks. From the time that the umbilicus is born the birth attendant has 4 minutes before hypoxia affects the baby [who aspirates as it attempts to breathe while still in utero or in the vagina]; yet if the head is delivered too quickly the difference in pressures can cause cerebral hemorrhage. Extended arms can render the head undeliverable [look up Lovset maneuver]. If the body is born before complete cervical dilatation [which often happens in prematures], it may be impossible to deliver the head at all. Want me to continue?
I simply do not understand this desire to avoid C/S at all costs. There are times when it is undoubtedly the safest for the baby -- and the only "success" in birth is a healthy baby and mother.
BTW, isn't it about time your CNM courses included some actual midwifery? Until now it has really been all theory, and most of that theory hasn't been about real midwifery. I keep waiting for you to get to the "hardcore" stuff
Antigonos - I actually can't argue with you at all about the risks of a breech vaginal birth.
Regarding the "hardcore" stuff towards my CNM: I did the "bridge" year in 2009, and started the MSN level work in Jan 2010. So, I truly am at the very beginning of the courses. The hardcore stuff doesn't really start until Jan 2011.
Next term: Research, Reproductive Physiology
Fall term: Pharmacology, Community Assessment
Winter 2010: Antepartum care 1 (YEAH!!!!!!!!!!!)
Antigonos - I admit was naive about the risks of breech birth when I planned my home birth. I honestly never thought it could happen to me. I did a lot of research when planning my home birth, although not specifically on breech. I've done more research about it since my vaginal breech experience and I realize the potentially serious risks now.
I never felt a need to fear then, nor do I now because I had excellent care and support. I had two experienced midwives at the birth, one of which has personal experience with almost 30 vaginal breech births, 3 of which were her own grandchildren. When it came down to it, I knew they would know how to handle any surprises that might come up.
I was not avoiding a cesarean "at all costs" either. Hospital transfer was always an option, but there was never a need for it in my case. I do believe I would have had an unnecessary cesarean had I been in the hospital, because it would have been done out of protocol or paranoia or both. My baby was monitored and was doing fine, and there was never a reason to transfer.
It's good to be aware of the risks and to be cautious, but I think hospitals are overly cautious, and not always for the right reasons. I had 4 vaginal vertex babies in the hospital under an OB's care. I'm glad I was at home with my breech.
Dear Cherelyn:
"I knew they would know how to handle any surprises that might come up."
No, they couldn't. Even the best team of doctors, working in a top-flight hospital can't. Which is why, if your doctor IS willing to attempt a vaginal breech birth in hospital, it is done IN THE OR, so that a C/S can literally be done in a minute.
NO midwife [or doctor, for that matter] can cope with massive hemorrhage, trapped head, severe hypoxia [along with transverse arrest, amniotic fluid embolus, etc. which are not particular to breech] at home. You were lucky, that's all. I'm glad for you.
BTW, for a birth attendant to have 30 breech deliveries in his/her career, since breech accounts for 6% of all presentations at delivery, that would mean that your midwife has done at least 5000 deliveries [yes, I know that sometimes one gets more than one's fair share. I have been involved with 3 fatalities due to amniotic fluid embolus, which is a bit above average statistically] Since it is very unusual for a homebirth midwife to do more than 100 deliveries a year [more usually 50 or less], and no hospital lets even a CNM do a vaginal breech delivery in hospital, I must take your midwife's claim with a grain of salt.
I've seen 2 breech vaginal births! One was the second twin - they were, if I remember right, 36 weeks, and the second twin just wouldn't turn so he was delivered breech. The second was a grand multip who had a history of fast labors, came in comlete and pushing, and the baby was coming no matter what. They actually went pretty smoothly, but with the second, we were all a little on edge until that head came out.
Antigonos - Yes, my midwife has had more than her share of breech babies, and after my experience I'm grateful she has.
I appreciate your input, but your harsh tone is offensive to me. Perhaps it's my fault for taking offense.
At any rate, you may believe I was lucky, but I don't believe in luck. There's another factor in play for me, and that involves prayer, spirituality and faith. We may just have to agree to disagree.
I see that you have extensive experience and must have great medical knowledge, and I admit I'm much younger and less experienced than you are. So I do appreciate your perspective, even if I disagree on some points.
I know that there are many supporting arguements to try to deliver a breech vaginally especially when there have been successful outcomes. I have been an L&D nurse for 20+ years and I have seen a few but the one delivery when the cervix clamped on the neck of the baby and the doctor couldn't deliver the baby alive... It's just not worth the risk, in my opinion.mf
I have been practicing for twenty one years and I believe I do about three breech vaginal deliveries per year. Most of the new residency graduates at our local academic center have never performed a singleton breech delivery and only a handful more have done so for a breech second twin. Breech deliveries are not just a lost procedure to the new graduates but there seems (I stress SEEMs)to be an over whelming perception in the public that breech equals brain damage. Maybe its the medical professions fault, maybe the attorneys, maybe some new wives tales. I recently had a laboring patient arrive at 38 weeks and diagnosed a frank breech of an about 6.5# infant. Scan revealed a well flexed head. Mems intact and 4cm cvx, 100% effaced. Pt was a primigravida and appeared educated. I showed mom the scan and we discussed options. The patient wanted to talk with her husband and mother and I rolled the scanner back to its closet. I walked back in and the pts mother requested that I find them another doctor as the idea that I had given the option of a vaginal delivery made the her feel I did not care enough about her grandchild to just proceed with a section. I asked the soon to be mom her opinion and she said to please just do a c/section. I did so and the child weighed 6# 5oz. When I left the OR I walked by the now grandmother and she apologized for questioning my intent and then volunteered that every breech delivery she had EVER heard of had resulted in some type of brain damage. My response was , yeah, and I know a pretty good case in point that was standing right in front of her.
I'm sorry if you perceive my tone as "harsh". I don't mean it to be, but I do call a spade a spade. The problem is that nowadays a lot of women do a bit of "research" on the internet, or pick their friends' brains, and think they are well-informed. I'm not being snide when I ask At Your Cervix about her courses. So far, it has really been like making stuffing when there isn't any turkey to put it into. Even a seminar on "Starting a Birth Center" is really only "padding". Throughout my entire career I have had to listen to unbelievable amounts of twaddle from supervisors with alphabet soup after their names, they've got so many degrees, but who have never actually dirtied their hands taking care of patients. At Your Cervix, however, has 9 years of working in a high risk L&D unit. That counts for a great deal, but believe me, when faced with the actual responsibility of managing a labor and delivery, and not augmenting and assisting the doctor who has the primary responsibility, one's attitudes change considerably and one becomes more cautious.
"Those who can, do; those who can't, teach" --- and that includes all those who think they know better than anyone else how to do something.
I find it interesting to read all the different comments and perspectives. I appreciate hearing other perspectives because it helps me learn and grow.
I have a question for those who work in the hospital and see how things play out on the doctor's side. Do you believe breech cases are truly considered on a case by case basis before automatically recommending a c-section?
My issue with hospital protocol is that they seem all too ready to wheel a mom into surgery. If surgery is necessary, then by all means do it. I just wonder how many of the c-sections being done are actually necessary. I'm sure it's not always clear-cut, but I would appreciate knowing that my doctor is considering my case individually and recommending what is best for me in that moment.
I'll chime in on that one Cherylyn. I have found that probably 95% of the doctors that I work with (and I work with a total of roughly 40 of them) will not even mention vaginal birth as an option to a mom with a breech baby. If she's a known breech and NOT in labor, a few will offer and attempt a version to turn the baby (if baby's position is optimal for that). If a mom presents in labor, is a known breech, or is discovered to be breech, about 95% or more of the doctors will say she must have a c-section. No options, minimal discussion. Some go as far as "a c-section is the only option, and we need to do this NOW" simply because she is in labor. And then, it's rush-rush-rush for the nurses to get her prepped and back to the OR. Our "goal" time of decision to incision for c-sections is 30 minutes or less.
So, where I work, you might as well expect a c-section if you're breech. If you're lucky enough to have a rare provider that is skilled and offers to try a version (before labor starts), you have an increased chance of avoiding a c-section.
Same with twins. If baby A is vertex and delivers vaginal, and baby B is breech, and fails a version right then and there after baby A is born, mom will get a c-section. It's rare to see a doctor where I work do a vag breech of baby B.
Thank you AYC, I think you just helped make my point :)
Personally, I would rather be working with a home birth midwife and her attendants who can give me their full attention and help me make decisions based on my individual situation, rather than with a care giver who has to divide their attention and time between several people at the same time and make decisions based on general protocol and the schedule.
I'm sure other people may come to a different conclusion after reading through these comments, and I respect that completely. I love that we are all unique in our character, background and experiences, and given the same information will come to the choice that's best for ourselves, whatever that is.
If the first baby is vertex on twins, then the second baby typically is delivered breech vaginally as well in my practice. CNMs can do breech at our hospital, with one of the collaborating physicians present. Breeches are only done under certain circumstances (multip, u/s for efw and flexed head, etc.). And it really depends who is on call as far as docs go. It really is case by case at our practice. If a woman is not in labor then any of our docs will be willing to attempt a version.
"Do you believe breech cases are truly considered on a case by case basis before automatically recommending a c-section?"
For a primip breech, no. Multips are a bit different. There are a number of factors involved, one being the size of the family the couple wants -- if they intend to have a lot more kids [or, for religious reasons, won't use contraception], avoiding C/S is definitely in the equation. As in everything else in OB, there isn't "one size that fits all". However, the overriding concern is that the policies of the hospital, which often depend more on its legal staff than on its medical one, often dictate what a doctor must do in a given situation, and if he deliberately flouts hospital policy too many times, he can lose his admission privileges [the hospital itself is constrained by the threat of loss of accreditation if there are too many bad outcomes.
As to the idea that the public has the idea that breech equals brain damage, the problem is that one is playing a kind of Russian roulette not with a water pistol but with live ammo. A bad outcome is NOT inevitable, but if it happens, the consequences can be dire. If you can avoid playing Russian roulette in the first case, isn't that more sensible? Or, at any case, that's the way most doctors think, especially since most of them have almost NO experience with breech birth [which raises the stakes even further]
There is no way to know if a C/S is REALLY necessary until after it's been done -- and even then, if the kid comes out pink and screaming, SOMEONE will claim that it shouldn't have been done. Of course, if everyone waits, and waits, and the baby is born dead or in extreme distress, the first question asked is "Why wasn't a C/S done?" [and, all too often, it's asked in court]
As I've said before, our methods of determining what is going on inside the uterus are limited; a birth attendant can only work on probabilities. This will inevitably mean that there will be unnecessary C/Ss until our technology improves.
I want to point out that because sections have become "not a big deal" to a large number of people (both patients and the medical community alike), there is little effort made to adress the breech position (assuming it's known) pre-birth. So many women have submitted to sections without experimenting with chiropractor care, acupuncture, movement, or even versions, because it doesn't seem worth the effort when a section doesn't seem to pose risks or negative side effects. It's the resignation to "baby's breech, so I have to have a section," without even trying to get the baby to turn that bothers me. Just my two cents- love your blog!
With my first baby, we didn't learn he was breech till I was fully dilated and ready to push...and by then I was in no shape to argue when they told me I would have a c-section. I hadn't done any research (I was having that baby naturally, darnit, and nothing would stop me! um...) on c-sections or breech babies, but looking back, I'm glad we took the safe route. I'm fairly certain everything would have been fine (baby was only 5 lbs 15 oz., and I have "birthin hips"), but I would want more than "fairly certain" when it comes to my baby. In my mind, the biggest drawback was that they made me have #2 via c-section as well...
(by the way - for those in the medical field - shouldn't my doctor have known the baby was breech? She did an internal exam only 2 days before he was born and pronounced him "head down," which he certainly wasn't - for a good week or so after birth whenever you laid him on his back his little legs folded straight back up by his ears - obviously the result of being folded in the womb for quite a while.)
Post a Comment