Our midwife lost a breech baby-questions? - Page 4

[ameliabedelia]

Or maybe I am getting mixed up with S-D?

Yes, I think you are.  I think Zanelli maneuver is only performed in dire cases and with shoulder dystocia.  It's for when the head is already delivered and they push the head back in.

In the case of a breech birth where the body is delivered, but the head gets stuck, I don't see how you could possibly push the babies body back up inside.  Yikes!  I think in they could only do certain surgical cuts to release the head (which they may still only want to do in the OR, since it will still would be a surgical procedure, just not a c-section).   

[calldeville]

No, I am a living breathing person (who lives in a house and not under a bridge). I would respectfully agree with a couple of previous posters and encourage the OP to look for another option or another provider. I have a couple of friends whose babies were breech, and they used a high-risk OB because of it. They now have healthy, happy, and very intelligent babies.

I guess it all depends on what level of risk you are comfortable with.

If someone is involved in a serious car crash and someone ends up dead, I think that person would be affected when driving a car for awhile. That says nothing about fault or blame, just a human reaction to living through a traumatic episode.

Another clarification. Breech may be common, but it is not normal. If a midwife is an "expert in normal birth" then I believe that means the baby is pointed in the right direction and the mom and baby have no additional health risks. 

[Alenushka]

The other question to ask is  about legality of breech delivery by this midwife in your state or country. In many sates and countries breech  babies are ricked out and MWs are not allowed to deliver them at home for safety reasons based on clinical statistics.

So, if the MW in question was doing it illegally it raises the question about professional ethics of this person.

[Alenushka]

What about this study?

"

In 2000, Hannah and colleagues completed a large, well-designed, multicenter, randomized clinical trial involving 2088 term singleton fetuses in frank or complete breech presentations at 121 institutions in 26 countries.^[9]

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001)."

[lex99999]

Originally Posted by Turquesa 
Obviously, as previously stated, it will depend on the baby's position, but SOGC supports the option for both frank and footlings.  A 2003 statement from them voiced support for midwifery, but I'm not sure of their official position on vaginal breech birth at home...

This is the last paragraph of the SOGC's decision: 

"The society is also cautioning that many breech deliveries will still require a cesarean section, and that a vaginal birth is not recommended for some types of breech positions. In situations where a vaginal delivery is an option, the delivery should take place in a hospital setting. An experienced obstetrician should be present to attend the delivery and to offer a cesarean section if the labour does not progress smoothly or if complications arise."

The SOGC doesn't endorse vaginal birth for footling breeches; only for frank or complete breeches. Here are their summary statements:

1. Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section.

2. Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section.

3. Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus.

4. With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes.

5. Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity.

 

 

It sounds like their position is that vaginal breech birth is riskier than vaginal cephalic birth, and that overall CS is safer for these babies. However, by risking some women out of vaginal breech birth, and by watching the ones who do qualify very closely, they're able to get good outcomes. Again, it's all down to the level of risk that the mother is comfortable with. 

[LLtheTinkerbell]

Originally Posted by Alenushka 

What about this study?

"

In 2000, Hannah and colleagues completed a large, well-designed, multicenter, randomized clinical trial involving 2088 term singleton fetuses in frank or complete breech presentations at 121 institutions in 26 countries.^[9]

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001)."

This study was reviewed and found to be invalid. Unfortunately between the time it was published and the time the reviews were done there was a sharp decrease in providers trained/skilled in vaginal breech births, hence the continued very high rate of c-sections for breech babies.

See the following (from breechbirth.ca/Research.html):

Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery

Andrew Kotaska, MD 

 

Kotaska suggests that for a complicated and highly variable situation such as breech birth, the method taken by the Term Breech Trial is inappropriate, and widespread acceptance of this trial's results has breached the limits of evidence based medicine.  The trial failed to adequately appreciate both the complex nature of vaginal breech delivery and the complex mix of operator variables necessary for its safe conduct, rendering the conclusion excessively simplistic and an inappropriate basis for a widespread obstetrical standard of care. Read this article at the BMJ site.

 

And:

 

Five years to the term breech trial: The rise and fall of a randomized controlled trial

Marek Glezerman, MD

 

Glezerman analyzed  the original term breech trial and finds fault with the study design, methods and conclusion.  Glezerman concludes that the “original term breech trial recommendations should be withdrawn.”

American Journal of Obstetrics and Gynecology (2006) 194, 20–5

 

[CEG]

Originally Posted by LLtheTinkerbell 

This study was reviewed and found to be invalid. Unfortunately between the time it was published and the time the reviews were done there was a sharp decrease in providers trained/skilled in vaginal breech births, hence the continued very high rate of c-sections for breech babies.

See the following (from breechbirth.ca/Research.html):

Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery

Andrew Kotaska, MD 

 

Kotaska suggests that for a complicated and highly variable situation such as breech birth, the method taken by the Term Breech Trial is inappropriate, and widespread acceptance of this trial's results has breached the limits of evidence based medicine.  The trial failed to adequately appreciate both the complex nature of vaginal breech delivery and the complex mix of operator variables necessary for its safe conduct, rendering the conclusion excessively simplistic and an inappropriate basis for a widespread obstetrical standard of care. Read this article at the BMJ site.

 

And:

 

OT, but what the heck, we've gone so far  I attended lecture by Dr Kotaska a few weeks ago.  It was phenomenal. 

[19spitfire]

Hi everyone, it's me the op.
I really appreciate the discussion going on here. I've been following along and thanks to you have gained some knowledge I can use when making my list of questions.
I do have a bit more information, although still no information about the type of breech.
What I haveearned it that the baby had shoulder dystocia and his heartrate was normal until 4 minutes before he was delivered. At that point 911 was called, but they took way to long to get there (@20 minutes). He was completely delivered 4 minutes after his heart rate was abnormal (I'm not sure if it stopped or what at this point).
So any more questions I can ask my midwife or references to studies are welcome with these new facts to look at.
Thanks again, it is really helpful to have all this thought put into my situation.

[mommato5]

Originally Posted by 19spitfire 

Hi everyone, it's me the op.
I really appreciate the discussion going on here. I've been following along and thanks to you have gained some knowledge I can use when making my list of questions.
I do have a bit more information, although still no information about the type of breech.
What I haveearned it that the baby had shoulder dystocia and his heartrate was normal until 4 minutes before he was delivered. At that point 911 was called, but they took way to long to get there (@20 minutes). He was completely delivered 4 minutes after his heart rate was abnormal (I'm not sure if it stopped or what at this point).
So any more questions I can ask my midwife or references to studies are welcome with these new facts to look at.
Thanks again, it is really helpful to have all this thought put into my situation.

She called 911 as soon as the heartrate became abnormal? Ok, so how often was she monitoring? What did she do in the time it took for EMS to get there? How far from the hospital and fire dpeartment does mom live??

Finally, who told you all of this????

[redpajama]

This thread has brought up so much that it's almost hard to respond to.  But here are my thoughts:

1. This midwife is not any less skilled, knowledgeable or experienced than she was when you hired her.  If this affects your own risk tolerance or judgement when it comes to your own birth, I think that's okay--I'm sure it will affect hers, at least for a while.  

2. A lot of posters are focusing on you getting the details of exactly what happened at this breech birth to lead to the death of this baby.  I think that, unless you are considering her as an attendant for an upcoming breech birth, the particular way she handled this baby--at least the breech-specific details--are sort of impertinent, except insofar as they reflect the midwife's practices in general.  

3. I'm not sure you'll have access to this information, but here's what I would want to know about my midwife in light of this situation:
--Did she accurately represent to her clients her training and experience with regard to breech?  Everyone will give you a different opinion as to how much experience is enough, what sort of training is ample, et cetera--but what is important to me is that her clients made their decision to stay home with complete and accurate information regarding their care provider.

--Were her clients completely and accurately informed of their options?  Did she discuss the local options for hospital birth (vaginal or c-section), the possibility (if there was one) of bringing in a more experience midwife, et cetera?  And were her clients informed of the risks of these options--the risk of vaginal breech, the risk of c-section, the approximate time it would take an ambulance to get them to a hospital if an emergency did arise, et cetera?  

I think there has been a lot of emphasis in this thread on whether or not it was safe/reasonable for the midwife to attend a breech birth at home, and on whether or not her skills and judgment were sound--and I think those are both really important issues, but also pretty arbitrary ones.  I think it's important not to overlook the central role that a client has in making decisions for her/their own birth, and the midwife's vital role in that process is to provide thorough and accurate information.

The other detail of the story that I think it pertinent to you, especially in light of this sort of unclear detail about the "abnormal heartrate" and the 4 minutes, is to know (which you might from your prior birth with her) what sort of resuscitation equipment she carries and whether or not her NNR certification is current.  I have a feeling that you're missing a piece on that detail--as it is, it just doesn't add up particularly well, in my opinion.  But if the baby's heart tones were, in fact, fine *five* minutes before the birth, I'm really surprised that the baby didn't respond extremely well to resuscitation and end up just fine.  I suspect, though, that maybe that detail is either inaccurate or incomplete.  But that's the other thing I would look into.

[Mama2Kayla]

Honestly, if it was me, I would find another care provider. I personally wouldn't feel comfortable giving birth with a midwife who recently experienced a loss like that.

I also wouldn't attempt a breech birth at home.  

[~~Sarah~~]

Originally Posted by ameliabedelia 

Yes, I think you are.  I think Zanelli maneuver is only performed in dire cases and with shoulder dystocia.  It's for when the head is already delivered and they push the head back in.

In the case of a breech birth where the body is delivered, but the head gets stuck, I don't see how you could possibly push the babies body back up inside.  Yikes!  I think in they could only do certain surgical cuts to release the head (which they may still only want to do in the OR, since it will still would be a surgical procedure, just not a c-section).   

So, I had the occasion once to ask an obstetrician who regularly attends vaginal breech births what the protocol was for head entrapment. He responded c/section. When I asked about the logistics of this (my exact question was "do you give tocolytics?") he explained that a regular low transverse incision was made and the baby comes out head first through the incision. (a "no" to my question). In the third world where c/sections are less common and more risky a "symphysiotomy" is performed for an entrapped head. Don't look it up. You don't want to know.

Secondly: OP? I don't understand the information you have provided. A shoulder dystocia is a complication of a cephalic birth and not of a breech birth. Something doesn't add up...

[Alenushka]

I read this too. Meta studies are not  such great things....and he is not a homebirthing doctor. He is in the hospital with a C-section stand by for vaginal trail breeches. I think it is quiet telling.

[abc123xyz]

Originally Posted by MommaBirdie 

I personally wouldn't continue with a care provider that agreed to a home birth for a breech baby.
Part of home birth is knowing when you need to transfer, labor with a breech is when you need to be in the hospital.
Does she not have privileges to deliver in a hospital?
 

That is unfair to say. I CHOSE to homebirth my breech baby after I was presented with my options and the possibilities because my midwife was experienced in breech and knew how to handle the situation, having had one herself and attended several. Ina May Gaskin just taught a seminar on it in NC last fall and never do they transport breech at the Farm unless the family decides they want to and have a low LOW rate of mortality, in the 1% area last I checked. It is irresponsible to say that across the board, being in labor with a breech necessitates the hospital. In that event, labor ends and surgery begins, where at home, you can have a great outcome with a lot less trauma and fear! Ultimately, the family must decide NOT THE CARE PROVIDER! I feel it unwarranted that because a Dr. has never seen a live natural birth with a breech that I should be considered a c-section because he is ignorant to the education out there. IN FEW OTHER COUNTRIES is breech automatically considered hospital and surgical worthy!

Originally Posted by Alenushka 

Wonderful journey of motherhood is not gonna happen with a dead baby. So, no, normally, healthy babies of healthy mothers do not die in childbirth unless the practitioner was incompetent.

I would not trust midwife with a breech birth. Ever. And definitely not the one under whose care the baby died.

To me, live baby and live mother is everything. I do not care about my experience more than I care about my baby being alive.

Babies DO INDEED die in childbirth. We in the US rank 43rd on the list in the world of infant mortality IN HOSPITALS!!!! Clearly babies do in fact die. For what reasons, that isn't clear. There are sometimes things that are not found during pregnancy or could be when the parents refused ultrasound, there are sometimes things that are irreparable, there are just sometimes unknown causes of death. It is not often that it's the incompetence of the care provider. It is truly not the care providers' rights to make informed consent decisions for their clients and their babies. Present the facts, give the pros and cons, and allow the family to decide. That's the downfall to the medical community and why there is such a distaste for alot of people toward the medical community.

[Jane93]

Once again -- infant mortality is not the correct measure.  Perinatal mortality is.  Further, to actually compare apples to apples, you must confirm the reporting regime used by each country.  Some countries consider live births at 22 weeks to be stillbirths, for example. 

[Jane93]

kseawall -- you made the choice that avoiding a c-section was worth it enough to you to risk a cord prolapse or head entrapment which would have likely resulted in a severe morbidity or mortality to your unborn child.  That's your right.   The odds worked in your favor.

But it should not be surprising that a number of other people's "risk calculus" is set more conservatively than yours.

[LLtheTinkerbell]

http://www.theglobeandmail.com/life/parenting/pregnancy/delivery/c-section-not-best-option-for-breech-birth/article1186104/

Originally Posted by Jane93 

kseawall -- you made the choice that avoiding a c-section was worth it enough to you to risk a cord prolapse or head entrapment which would have likely resulted in a severe morbidity or mortality to your unborn child.  That's your right.   The odds worked in your favor.

But it should not be surprising that a number of other people's "risk calculus" is set more conservatively than yours.

[cinderella08]

Originally Posted by LLtheTinkerbell 

http://www.theglobeandmail.com/life/parenting/pregnancy/delivery/c-section-not-best-option-for-breech-birth/article1186104/

This was a great article.
 

[CEG]

Originally Posted by Jane93 

kseawall -- you made the choice that avoiding a c-section was worth it enough to you to risk a cord prolapse or head entrapment which would have likely resulted in a severe morbidity or mortality to your unborn child.  That's your right.   The odds worked in your favor.

But it should not be surprising that a number of other people's "risk calculus" is set more conservatively than yours.

Choosing a c-section results in increased risk of blood clots, hemorrhage, infection, amniotic fluid embolism, breast feeding problems, etc for mom.  For baby it results in increased risk respiratory distress, hypoglycemia, hypothermia, breastfeeding problems etc.  You trade one set of risks for another, it's not as though c/s is a risk free alternative.  Current research shows that long term outcomes are the same for vaginal breech vs c/s.

[Alenushka]

People, stop comparing  apples to oranges. Please. Homebirth and midwives in Netherlands are not the same as they are in US. Infant mortality rate are not the same thing as neonatal rates.