breech extraction questions

[butterflies]

I've found a practice where (unlike many in my area) all 4 drs are very comfortable and experienced with vaginal breech births. If baby is A vertex and B is breech that's fine with them. They are also willing to consider vaginal delivery even if both babes are breech, since I have already given birth before.

My question is about the "extraction" part of a breech extraction. I'll ask for more details at my next appt but maybe you can help me frame my questions.

If you had a breech baby B-- is it reasonable to ask the drs to allow some time (how much?) after the first baby is born so the breech baby has a chance to turn? Is changing positions at that point (a la spinning babies) even feasible? I'm guessing it would be tough to move about unless the cord was clamped and cut after baby A's birth. I know that's another whole set of questions-- these babes are monozygotic and share a placenta.

Does extraction usually mean they reach up and immediately deliver the second baby while the cervix is still fully dilated from the first delivery? When does it make sense to allow a breech birth to proceed with minimal "management"?

I may be over-thinking it... I'm one of those people who has to research every detail. (fortunately dh is the same-- when dd was born he had prepared a flow chart in case he needed to discuss decisions with the hospital staff )

[queenofchaos]

It's great you've found drs who are willing to do breeches, that's a pretty hard find! I have an OB who is also willing to deliver vag. so long as baby A is vertex. I just had an appointment with him today and asked him some more questions about the birth. I wanted to know how quickly he would want to get 2nd baby out once the 1st was born. He said that so long as baby was doing fine, then there was no rush. Somewhere in the conversation he also mentioned that sometimes even if both are vertex, once the 1st is out, the 2nd will flip around because suddenly there is so much room. Regardless, tho, as long as 2nd babe is doing Ok, then he would try to get baby repositioned, or if breech position was Ok (don't want an arm presenting) then would go forward with breech delivery when baby and I were ready. I think the main thing is how baby is tolerating the process. (Mom, too of course!) I can't speak for your drs, but it makes sense to me and sounds reasonable. IHTH.

[spinningbabies]

Butterflies' breech twins

Dear Butterflies,
If the first twin is born and the 2nd twin is breech or transverse, giving some time for the womb to shrink and contractions to strengthen again (they may get milder after Baby A is born) allows the 2nd twin to self-flip to a head down position. An upright position may help.

While breech extraction of the second twin is safer than breech extraction of a singleton, it is risky. Talk to your doctors about whether this is a procedure they would plan on routinely or only if the placenta had released before the 2nd twin was ready to be pushed out in one or two pushes. Find out what hands off the breech means to them. Often people use a phrase but do not always share the same meaning.

When does it makes sense to allow the breech to come spontaneously and with minimal management? Dr. Frank Louwen of Frankfort Germany, and breech expert midwives Mary Cronk and Jane Evans in the UK, all of whom have excellent breech statistics for safety, to
1. Ask mom to be on her hands and knees once the breech is visible.
2. Spontaneous pushing -the mother pushes with her body's own urging, not on que unless there is an exception late in the pushing process.
3. When the baby's ribs are appearing, the mother's position allows the weight of the baby to rotate the baby to sacrum anterior (from behind the mom on her hands and knees the doctor sees the baby's umbilicus and chest). With the baby in this position AND a well pulsing blue cord, the baby can be allowed to remain UNTOUCHED for the arms to appear spontaneously (be born without help).
And then the head, too. As the baby drops to the bed or padded floor the doctor then touches the baby for the first time while catching the baby, literally catching in this safest way to catch a breech.
4. If the baby doesn't rotate to Sacrum Anterior when the ribs are being born, then the doctor considers the cord, if pulsing can wait till next contraction, but if still stuck or cord isn't full and blue, than the doctor rotates the baby towards the wrist of the baby, and reaches up behind the baby to sweep the posterior arm to the baby's chest and out. Repeating for the other arm if necessary. It takes literally seconds.
5. The head can now wait for the next contraction and the doctor can assure that the head is now occiput anterior (though technically SA, but the occiput is all that is left inside for a landmark at this point).
6. If the head doesn't come, the doctor flexes the head and the head will come out.
there are tecniques for this. The new feeling is Not to put a finger in the baby's mouth.
7. After the birth, the baby rests between mother's knees while the cord refills and nature resusitates a quiet baby if necessary. Either way, crying or stunned, the cord should be left to pulse another bit until the baby gets her or his blood back from the placenta.
8. Skin to skin contact is lovely for baby now.

This is currently and with the great stats of these practitioners the way to have the safest breech. Hands and knees make any needed adjustments of baby's diameters very easy to acomplish. But also less likely if no one touches and startles the baby, including vag exams.
Thats my opinion, but also their stats.

Love to you and your birth!

[DiannaK]

I had a breech extraction of Baby B, in the hospital OR.

I was worn out after delivering Baby A --- I seriously wanted a breather. Not a long pushing deal with him, but I had prodromal labor for weeks, and when the real thing finally hit me, it was like a freight train.

This is what I remember ---- Baby A goes over to the nurses, and OB checked my hoo-ha and told me that I HAD to push when she told me to. I asked her if I could take a break, and I remember my husband telling me I couldn't, and I cried.

I know she had her arm inside me (sorry to be graphic), and I think she was trying to prevent cord prolapse. His water was still intact, I think, because I recall a big gush, the OB and then my husband yelling at me to push, and then Baby B being born. I think she was doing all that sweeping around so that she could get both of his legs pointing down. I don't know if he was like a frank breech, or footling, or what. I don't know if he was having trouble with his heart rate, or if she was just in a hurry since it was a breech extraction, maybe something she wasn't comfortable with, or she was nervous because I did not have an epidural.

Now you make me want to call and get the operative note!

Good luck -- even with it being painful, I was totally OK with it, versus having a section.