twin vaginal birth... breech extraction vs natural breech delivery? studies?

[turnquia]

Ok... so I trust my OB's whole heartedly... we are still planning a homebirth and they know this. But I would like to see if anyone has seen or heard of what he's referencing? (Twin B is breech, this is whY i'm asking)

Breech extraction of 2nd twin is safer in terms of apgar etc for baby B than a Breech birth without intervention?

He claims studies have shown their apgars tend to be better if they just do a breech extraction rather than allowing them to be born whenever they are ready.

Now I know my homebirth midwives don't do breech extraction unless there is distress.

But i'm curious what study he is refering to, and if there is anything more recent that would suggest otherwise that I can take to him.

[Gena 22]

You've got plenty of time for that little one to turn!

But what exactly is the claim? That a breech twin B, born breech, does better than a singleton breech? I think I may have read that somewhere but wanted to clarify what your OB was saying.

What is a breech extraction v. natural breech delivery?

[kitkat5505]

I had never heard that, though a lot of the twin stories I read with Baby B breech the OB will do extraction vs waiting for baby come when ready. I heard that it was because with B breech there is more chance for cord prolapse or compression so they just try to get them out quick so that doesn't happen.

[turnquia]

Originally Posted by kitkat5505

I had never heard that, though a lot of the twin stories I read with Baby B breech the OB will do extraction vs waiting for baby come when ready. I heard that it was because with B breech there is more chance for cord prolapse or compression so they just try to get them out quick so that doesn't happen.

Yes this. It has very little to do with breech delivery and more on the whole twin thing.

He said somewhere there is a study of twins that breech extraction is safer in terms of apgars than waiting for baby to come down on its own. Some of it due to cord prolapse and other issues. As well just grabbing baby is easier than hopeing they don't flip into something like a funky transverse. (Although if there is that much room for them to stick their whole arm up there and grab baby, it seems like there would be enough room to push baby around into a decent position).

But I would like to see this study on my own. And see if there are any more recent studies that show anything to the contrary. My Ob's are very respectful in my wishes for a natural birth, and even a homebirth. But we have discussed what it a hospital birth is necessary... and this was one of the things we've talked about.

[nudnik]

What does "safer in terms of Apgars" mean? My footling breech twin was 7/10, obviously from being breech, but maybe it's supposed to be that way? A lower first Apgar isn't going to cause any long-term damage, but I imagine that an extraction comes along with its own risks (even if some of those are unknown).

My gut feeling is not to mess with the process unless there's some concrete indication that intervention is necessary.

[turnquia]

Originally Posted by nudnik

What does "safer in terms of Apgars" mean? My footling breech twin was 7/10, obviously from being breech, but maybe it's supposed to be that way? A lower first Apgar isn't going to cause any long-term damage, but I imagine that an extraction comes along with its own risks (even if some of those are unknown).

My gut feeling is not to mess with the process unless there's some concrete indication that intervention is necessary.

As is for my gut instinct.. however I could be wrong. So I'm looking for any evidence for these comments from him. He will have a copy of the study he was refering to me in a month, as I will have my own for him. This is what I love about him... its a nice open discussion and learning process for myself, as well as I may find something for him he didn't know.

He was refering to a study in which 2nd twin was breech, that baby with a breech extraction had better apgars than babies who were allowed to progress on their own. Babies allowed to progress on their own have increased risk of cord prolapse and a few other things... so generally a breech extraction was reguarded as being safer since apgars were improved amonst the group. I'd also love some information on why a breech extraction isn't safe.

This is also a discussion with our midwives for our homebirth, but mainly this is for the OB in the event of transfer or delivery prior to 36 weeks. He's open to anything, but for either of us to feel comfortable with changing our opinions it gotta be evidence based practice. Sure if I feel he's wrong I will refuse his opinion... but I won't need to refuse it, he's a level headed guy, who has told me "I trained to be an OB in the 80's, when EVERYTHING came out of a vagina". He's comfortable with breech, he's comfortable with vbac and pushes for them... its only if it seems to be safe. The fact he's willing to do singletons breech when you cannot do an "extraction" makes me think there is some merit to what he's saying. I just want to see the study for myself, and know the risks before consenting to anything like that. IF its even necessary to consent to

[butterflies]

turnquia-- I have had exactly this question for some months and I haven't been able to find such a study in the medical literature. And I've spent a lot of time searching. None of the studies I've seen differentiate between "total breech extraction" and "assisted breech delivery".

A number of studies compare "breech extraction" to attempted external version after delivery of twin A (the consensus seems to be that extractions have better outcomes overall) or "breech extraction" to planned c-section. But my sense is that these categories group ALL breech vaginal deliveries of twin B under the heading "breech extraction"-- regardless of how much manipulation the dr actually performed.

I'm a biomedical scientist and I have access to all of the journals cited on PubMed. If your dr could provide a reference, I'd be very happy to pull up the full text!

Personally I feel that if the 2nd baby's amniotic sac has not ruptured, there is a lot of value in watchful waiting and using positioning to encourage baby B into a cephalic presentation.

Someone else asked about singleton vs twin breech births-- and yes, it seems the medical community feels (at least a little bit!) more comfortable with a twin baby B breech because a vertex baby A has already caused the cervix to fully dilate. I'm definitely not an expert but this is what I've been able to glean from the past few months of reading!

[turnquia]

Amy- Thank you for your response. I too have full pub med access and a few other sites and cannot find anything either. So I'm not sure what study he's refering to. But he was specifically stating breech extraction vs spontaneous breech delivery. But I have to talk with my specific OB a bit more in depth at our next appointment. Unfortunately I was in a bit of a rush to keep asking any further.

I agree if membranes aren't ruptured why mess with things... also upright delivery will facilitate a turn of baby B, because their heads are the heaviest. My little guy is cock eyed so once she comes out, he will most likely rotate right along her feet (that's my guess)

But I have to talk a bit more in depth with homebirth midwives. In the event of complications, are they capable of doing a breech extraction (which I have read can be done very quickly if necessary). And how have previous births gone for them with twins. I know they've had good outcomes and are pretty experienced but I need the mental picture in my head set up going into this, especially with twins being a bit higher risk.

I'll keep looking! And if I can get some info from him in the mean time... (I think I'm going to call office and ask if he can give me some reference to what he's talking about) then I will share it here!

[turnquia]

Well I found one study... lol but it doesn't back up my OB

http://emedicine.medscape.com/article/262159-overview

As long as the fetal heart rate is stable in this situation, it is permissible to manage expectantly to allow the cervix to completely dilate around the breech

Its does mention the only time a breech extraction is acceptable is during a twin delivery of baby B.

[turnquia]

This is another one I'd love to read.... will have to log on thru pub med later... doing a google search for now.

http://informahealthcare.com/doi/abs...ournalCode=jog

Our findings have allayed the fear that non-vertex vaginal delivery of the first or second twin is dangerous. We conclude that in the absence of a uterine scar or a footling presentation, there is no valid reason to prohibit vaginal delivery when either twin presents by the breech.

[turnquia]

Hehe... I think i'm gonna get my way in this whole discussion with him. Wonder what study he was refering to...

link

ETA: For any twin moms... READ this. Its a great one also discusses the whole twin A being breech isn't necesarily criteria for a c-section.