Re: Breech
From: David Priver, MD (dpriver@aol.com)
Tue Dec 14 18:55:32 2004
This is truly one of the saddest issues in obstetrics. Both Hannah and
ACOG notwithstanding, a carefully selected and followed breech delivery
is simply not that big a deal. I still do several a year and have never
had occasion to regret it. Critical issues: 1. Good documentation and
consent, as others have mentioned, 2. Good anesthesia; only difficult
ones I've ever seen have been in unanesthetized patients, 3. Good
progress; any arrest in active phase and it's all over; if she won't
agree to that, don't even go near her; show her the door. 4. Sit on
your hands during 2nd stage until umbilicus delivered; if she can push
it out, you can catch it. 5. Have a gloved assistant next to you, in
case you need Pipers (they're pretty easy to use, so don't panic; give
her 3 or 4 pushes and if the head is not delivered, apply them. 6.
Nothing wrong with a fetal electrode applied to the buttocks, (but do
try to stay away from the scrotum).
Let us know how it works out.
DP
PS: Has anyone ever read a study as bad as Hannah; truly outrageous, but
our leaders didn't have the courage to criticize it.
At Tue, 14 Dec 2004, Henry Gregor wrote:
>
>I would protect your future ability to practice obstetrics w/o stress and distraction of depositions by insuring patient's situation conforms to the published (multiple times, multiple places) criteria for trial of breech vaginal delivery, such as: nonstargazer, what type breech presentation, pelvimetry assessment (only really clinically effective assessment ... google Friedman, or Henry Klaphotz, and Ball pelvimetry. Both published computer algorithms for calculating fetal and pelvic compartmental volumes, and updates to MRI data as opposed to xray data have been done.), be explicit prior clinical pelvic trial won't necessarily convey assurance with another fetus, even one of lesser weight, might reference fact that even in appropriately selected trial breech labors there is a bottom line incidence of intrapartum fetal/neonatal injury (Survey of Obstetrics and Gynecology did a great comprehensive review of this some years ago.)....patient autonomy dictates patient's right to make
> informed choices, though you need to document, document, document...I know, sounds like the liability insuror's risk management director. And, what's the patient's attitude and plan re intrapartum situations which might lead to recommendations for C/S then? I think the patient has a prerogative to go the route she wishes, and in a better world of patient physician interaction, all this obsessing with documentation etc. would ideally not be required....but we're not in that world.
>
>Hank
>
>"art fougner, md" <evsono@pipeline.com> wrote:
>a minefield to be sure ... even Hannah's group admits that the longer
>follow-up suggests little difference in childhood development, assuming
>no mishaps during the birth process occur ... and there-in lies the
>rub.
>
>At Tue, 14 Dec 2004, Elrod Darryl G MAJ 48 MDOS/SGOBO wrote:
>>
>>32 yo G4P3 at 36wks and breech. First delivery was delivered breech
>>after failed version. Next deliveries were vaginal without
>>complications. She doesn't want a c/s and if the version fails this
>>time she wants to deliver vaginally.
>>
>>In light of ACOG's stance on vaginal breech deliveries, how would you
>>handle this situation?
>>
>>I'm personally inclined to let her attempt a vaginal breech delivery.
>>She obviously has a proven pelvis. She understands the risk associated
>>with delivering breech.
>>
>>Thanks,
>>
>>Glen
>>
>>D. Glen Elrod, Maj USAF, MC
>>
>>Obstetrician/Gynecologist
>>
>>Maternal Child Flight
>>
>>48 MDOS/SGOBO
>>
>>UNIT 5210 Box 23
>>
>>APO, AE 09464
>>
>>DSN (314) 226-8334
>>
>>Comm 01638-52-8334
>>
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>
>--
>art fougner, md
>ich bin ein New Yorker
>
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