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Vaginal breech birth - cord compression?

post #1 of 11
Thread Starter 

Hi,

 

I recently watched several homebirths where the baby was breech on YouTube, and in one it was clearly possible to see the cord hanging out after the body was born. Seeing this made me wonder if there is any risk of the baby's oxygen supply being cut off? How soon after the body should the head be born with breech births? Is there anybody here who thinks that c-sections for breech babies are justified?

 

Thanks,

 

Olivia

post #2 of 11

The risk of the baby's oxygen supply being cut off at that point of the birth (ie. body out, head in) is near 100%. That is part of the rationale for c/section.

So the question remains "how long do you have with the body out, head in with no blood or oxygen supply, before the baby becomes compromised?". The answer is always "depends on the situation". You might have a solid 8 - 10 minutes if the baby has not been compromised beforehand. You can just as easily have only 30 seconds. You can't know in advance. You can make educated guesses depending on a variety of factors... Then the question for a care provider becomes "how fast can I get the head out, if I should need to do so quickly?" If said care provider has little to no experience with vaginal breech birth the answer becomes "I have no bloody clue, and I don't want to find out the hard way." So that is one justification.

 

Do I believe that's the solution? . . . headscratch.gif

post #3 of 11

 

Quote:
The risk of the baby's oxygen supply being cut off at that point of the birth (ie. body out, head in) is near 100% 

 

Where are you getting your statistic? I looked it up and couldn't find anything to support your claim.

post #4 of 11

The reason breech vaginal births are more risky than cepahlic vaginal births is that with cepahalic births, the biggest, least compressible part of the baby engages first, and then the rest of the baby follows after everything has been stretched by the head. With breech, either the buttocks or the feet come out first, so by the time you get to the head, the birth canal might not be stretched enough to accomodate the head. After the baby has been delivered to the neck, the head has to stretch the canal enough for it to pass through. However, the baby's umbilical cord is also in the birth canal (remember that the baby's abdomen is outside), so while the head is fully engaged and stretching out the birth canal, the umbilical cord is being compressed between the head and the birth canal. That is why head entrapment is so dangerous- if the head is stuck, the umbilical cord is also being squeezed, and there's a limited amount of time to get the baby out.

post #5 of 11

Oh, and to answer OP's question, I think CS for breech babies is absolutely justified. My risk tolerance just isn't that high, but your milage may vary.

post #6 of 11

Here's what the current SOGC (Society of Obstetricians and Gynecologists of Canada) guidelines state: 

 

"After the breech crowns, fetal expulsion is invariably accompanied by cord compression and fetal bradycardia. The normally grown fetus enters this phase well oxygenated without acidemia. It may tolerate a number of minutes of delay with extrinsic cord compression, resulting in a respiratory acidosis, easily reversed once ventilation is established. A growth-restricted fetus, however, has a high likelihood of metabolic acidemia in labour due to pre-existing compromise in placental function, which reduces its tolerance to cord compression during expulsion. Therefore, fetal growth restriction is a contraindication to labour.

Significant cord compression beyond several minutes will eventually lead to severe acidosis even in a normal fetus, and prevention and treatment of expulsive delay are critical components of delivery technique."
 
 
As the PP described above, the cord becomes compressed between the fetal head and the cervix. You may see some claims that if the cord is pulsing, then all is fine and it is not compressed. This is not true. The cord pulses because of the baby's heartbeat and the flow from the baby's body. All you can tell by the pulses is that the baby's blood flow is affected the visible part of the cord. You can't tell how significant the compression is and how much blood flow to baby is occurring. 
post #7 of 11
Quote:
Originally Posted by phathui5 View Post

 

 

Where are you getting your statistic? I looked it up and couldn't find anything to support your claim.



It's not a statistic. It's simple logic: hard head + vagina + something that is easily compressed = the cord gets pretty darn compressed.

 

 

post #8 of 11
post #9 of 11

Quote:
Originally Posted by cinderella08 View Post

Good information on vaginal breech deliveries.  http://www.theglobeandmail.com/life/health/c-section-not-best-option-for-breech-birth/article1186104/

 


This is the same article (and SOGC breech birth guideline) that I just referenced in a different 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 #10 of 11


 

Quote:
Originally Posted by lex99999 View Post

 


This is the same article (and SOGC breech birth guideline) that I just referenced in a different 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. 
 

 

 

Right - I read the article in full when it first was released.  It does have some excellent, excellent general info on breech vaginal deliveries though which is the only reason I posted it. 

 

I actually have a client who's baby still does have time to turn around, but is breech at 36+ weeks and she's printed this article to discuss with her OB.  She's a muli-p (4th baby - all vaginal births thusfar) so she has a proven pelvis no doubt.  Baby is measuring right on track and isn't estimated large.  Baby is frank breech currently.  She would seem like a great candidate from the above information, but OB is currently refusing to even consider a TOL.

 

post #11 of 11
Quote:
Originally Posted by cinderella08 View Post

Right - I read the article in full when it first was released.  It does have some excellent, excellent general info on breech vaginal deliveries though which is the only reason I posted it. 

 

I actually have a client who's baby still does have time to turn around, but is breech at 36+ weeks and she's printed this article to discuss with her OB.  She's a muli-p (4th baby - all vaginal births thusfar) so she has a proven pelvis no doubt.  Baby is measuring right on track and isn't estimated large.  Baby is frank breech currently.  She would seem like a great candidate from the above information, but OB is currently refusing to even consider a TOL.

 


Yup, even in Canada there aren't many OBs who feel comfortable enough with vaginal breech births to attend one, so if her OB isn't comfortable with vaginal breech (and the baby doesn't turn), she may have to look around to see if any in the area have more experience with them. I know it's a huge problem to find an OB to attend breech vaginal births in some areas, so hopefully she'll be able to find someone if she's really set on vaginal birth. 

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