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Our midwife lost a breech baby-questions? - Page 5

post #81 of 94

Jane93 I'd be curious to hear what your thoughts on homebirth are in general.

post #82 of 94

I think that my feelings on homebirth are a big "it depends". 

 

Are we talking homebirth attended by an OB, a CNM or a CPM or a UC?   Beyond the "letters behind the name" what is the skill set we are talking about?  What are availability of back-ups?  Integration of transfers?  Availability of hospital care in the area?

 

Are we talking about a truly low-risk pregnancy, or someone who refuses standard testing out of a fear that she might be risked out of "her" homebirth?  Are we talking about someone who wants to pretend any issues are just "variations of normal"? 

 

For homebirths I have the following additional concerns:

 

(1)  The fact that midwives in many jurisdictions seem to practice without real accountability to anyone.

 

(2)  That frequently those with the least training (CPMs) are operating in a place (the home) with the least resources when things go wrong.

 

(3)  Many of the philosophical underpinnings of the homebirth/NCB movement are troubling.  The fatalistic "some babies just die" attitude.  The idea that if something goes wrong it is the mother's fault for not having a positive mental state (or whatever other BS someone wants to throw at her).  The whole "trust birth", "variation of normal" mantras -- they mean nothing and are just attempts to dissuade someone from weighing risks on a deeper level.  For example, for a breech birth, the risks are the risks, whether you call a breech birth a "variation of normal" or call it abnormal.

 

[more to come]

 

 

 

 

 

post #83 of 94


This is the same article (and SOGC breech birth guideline) that I referenced earlier in this thread. If you read the guideline, they are definitely not giving a blanket approval to vaginal breech birth. The guideline says that the breech baby should be frank or complete breech, with a flexed or neutral head, the mom's pelvis has to be shown to be adequate (so probably no primips), and the baby has to be between 2500-4000g (5lb 8oz - 8lb 13oz). If those criteria are met, continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage, second stage may last up to 90 minutes, and pushing may not go more than 60 minutes. From the second stage, labor should take place either in or next to an available operating room, and NICU staff has to be on standby. Yes, they say that certain women can elect to deliver their breech babies vaginally, but only by following the above guidelines do they have good outcomes for the babies. This tells me that home birth with a breech baby would be way too risky for me, but every woman has to weigh the risks herself. 

 

post #84 of 94

A moderator moment:

 

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post #85 of 94

Had this happen about tow months ago with a 38 week breech.  Head absolutely trapped and cervix clamped around the neck.  You can't do a vacuum on a breech.  You cannot put Piper forceps though a clamped down cervix.  An episiotomy does not solve the problem.  Zavinelli's maneuver is for vertexwith shoulder dystocia,  and the few I have heard of had very bad/fatal outcomes

 

I did a modified Duhrsenn's incision on the cervix, and delivered the baby.  Apgar 6 and 9.  If your midwife doesn't know what a Duhrsenns is  then she really can't handle the one emergency we all fear--the trapped head.

 

Have done several hundred vaginal breeches---still do them ---and  knock on my wooden head---haven't lost a breech baby during the birth process yet.  It is hard to convince women that they CAN deliver vaginally--there is a lot of social media against it.  Have done several breech breech twins.  All said ---sudden things can happen, and I have had to tell several women over the years that --during a completely routine prenatal visit--that no heartbeat can be heard---usually a cord accident--most other causes would have something else--ie bleeding, fever, pain etc.

 

I would want a CNM to have done at least 10 breech deliveries before she flies solo---during residency we had to have 150 under our belt--easy to do in a large tertiary center.  It is sad that vaginal breech is becoming a lost art.  I just hope the Americans embrace the same recent ideology that the Canadians have----that vaginal breech needs to be brought back!

post #86 of 94

Had this happen about two months ago with a 38 week breech.  Head absolutely trapped and cervix clamped around the neck.  You can't do a vacuum on a breech.  You cannot put Piper forceps though a clamped down cervix.  An episiotomy does not solve the problem.  Zavinelli's maneuver is for vertex with shoulder dystocia,  and the few I have heard of had very bad/fatal outcomes

 

I did a modified Duhrsenn's incision on the cervix, and delivered the baby.  Apgar 6 and 9.  If your midwife doesn't know what a Duhrsenns is  then she really can't handle the one emergency we all fear--the trapped head.

 

Have done several hundred vaginal breeches---still do them ---and  knock on my wooden head---haven't lost a breech baby during the birth process yet.  It is hard to convince women that they CAN deliver vaginally--there is a lot of social media against it.  Have done several breech breech twins.  All said ---sudden things can happen, and I have had to tell several women over the years that --during a completely routine prenatal visit--that no heartbeat can be heard---usually a cord accident--most other causes would have something else--ie bleeding, fever, pain etc.

 

I would want a CNM to have done at least 10 breech deliveries before she flies solo---during residency we had to have 150 under our belt--easy to do in a large tertiary center.  It is sad that vaginal breech is becoming a lost art.  I just hope the Americans embrace the same recent ideology that the Canadians have----that vaginal breech needs to be brought back!

post #87 of 94

What happens to the cervix later after it heals as far as competency in consequent pregnancies?

post #88 of 94

I've heard stories of pretty severe cervical damage (like from a resident practicing with forceps! ouch) that were followed by healthy full term, vaginally born babies. 

 

Hey! A vaginal breech supporting OB! :) Welcome!

post #89 of 94
Quote:
Originally Posted by Alenushka View Post

What happens to the cervix later after it heals as far as competency in consequent pregnancies?


I don't think there are any controlled studies--but it may be a possibility---one to check for in future pregnancy---however  at the time of a cervical clamp down---I really don't give a tweet about the future maybe's---I got a bird in the hand NOW and I am not sacrificing a viable baby for a potential loss of a previable fetus--so just hope no cerclage needed but they are easy enough to put in.  Hope that doesn't sound heartless---just practical!

 

You've got three minutes to get that head out---before you start shopping in special needs catalogues  or worse --- shopping for caskets.

 

post #90 of 94
Quote:
Originally Posted by Alenushka View Post

What happens to the cervix later after it heals as far as competency in consequent pregnancies?


I don't think there are any controlled studies--but it may be a possibility---one to check for in future pregnancy---however  at the time of a cervical clamp down---I really don't give a tweet about the future maybe's---I got a bird in the hand NOW and I am not sacrificing a viable baby for a potential loss of a previable fetus--so just hope no cerclage needed but they are easy enough to put in.  Hope that doesn't sound heartless---just practical!

 

You've got three minutes to get that head out---before you start shopping in special needs catalogues  or worse --- shopping for caskets.

 

post #91 of 94

I am curious as to why a CNM needs less than a 10th of the experience of an OB resident to attend breech births alone at home?  Do you view the OB required minimums as being way too cautious? 

 

How do you feel about CPMs attending breech births?

post #92 of 94
Quote:
Originally Posted by Jane93 View Post

I am curious as to why a CNM needs less than a 10th of the experience of an OB resident to attend breech births alone at home?  Do you view the OB required minimums as being way too cautious? 

 

How do you feel about CPMs attending breech births?


We were only required to do 3 as an intern--I know I got more because I knew I wanted to be an obstetrician and hung out on the labor floor a LOT--same as any family practitioner who may be going into rural medicine---just in case someone presented to the ER and working in a place with no OB services.  We had a rural medicine program where residents would do 6 months of OB/surgery and were trained to do C. Sections, low forceps and vacuums and had to do at LEAST 6 breeches --most got more than that (we did over 4000 deliveries a year at just ONE hospital in the city I trained and we had 5 other hospitals so plenty of deliveries--at least they HAD some experience with obstetrics and with breeches.  Of course, KNOWN breeches/twins etc were transferred to a tertiary facility--where believe it or not we did NOT section breeches routinely--we delivered well over 80% vaginally--we were largely trained by Irish and Scottish doctors.  The OB family practice basically did low risk deliveries and did not do PLANNED breeches---but if someone came in early at least they had someone with SOME experience.

 

I realize that the tide is such that women will choose home birth---some for altruistic reasons and some --especially the UC group may be planning it more because we have a crappy health care system here that cripples our citizen's finances==but that is another post.  I would just like to see some standardization of midwifery----that some number (and I don't know now what that number IS), of deliveries be supervised and signed off on before flying solo.

 

post #93 of 94
Quote:
Originally Posted by Jane93 View Post

I am curious as to why a CNM needs less than a 10th of the experience of an OB resident to attend breech births alone at home?  Do you view the OB required minimums as being way too cautious? 

 

How do you feel about CPMs attending breech births?

...and I guess I don't really understand what a CPM does.....   I have worked with CNM's  so know what they do.  I have a little problem with the idea being that  they attend normal low risk deliveries--and then the line of what constitutes low risk has been--from what I see here--virtually erased---HVAC, HVAC2, twins, breeches.-etc.

 

I have seen a couple of uterine ruptures and they are ALARMING---last one THIS year was a women who showed up with no prenatal care and 10 cm---actually had everybody there and thought we would get a vaginal birth---I have done VBAC2s in the past many times---but BOOM  ------Absolute WATERFALL of blood---I would say 750 ml-----thankfully we got the baby out with crash section withing 4 mins.  I have no doubts that both would have died at home---her blood loss was well over 1500ml and required VIGOROUS resuscitation.  I could do without another rupture---my anal sphincter is aging and may not hold up to another! 
 

 

post #94 of 94

How do I unsubscribe from this thread, since you deleted my comment and all... obviously my perspective is not wanted in this "open exchange of ideas" so stop sending me emails about it...

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