OB recommends repeat c/s for breech B?!?!! X-Post VBAC - Mothering Forums

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#1 of 42 Old 07-28-2009, 09:19 AM - Thread Starter
 
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Baby B flipped breech during my last ultrasound 2 weeks ago (33w) probably because I was on my BACK at the hospital for an HOUR. She has not flipped back vertex according to u/s today.

So now my doc is talking about ERC (elective repeat c/s) if she doesn't flip vertex. I knew that ERC was obstetric protocol for breech baby A, but why for baby B? He says that doing a version on baby B could be risky - possible cord entanglement or too much stress on the cesarean scar.

Is this justified? I know that his insurance provider does NOT cover breech delivery. He's been practicing long enough that he used to do breech until his insurance shut him down.

So, the way he couched it was that there's a lot of "controversy" and not good evidence to really support WHAT to do when baby B is breech in a VBACing mom. I'm not finding evidence to suggest that (1) breech B is a problem; (2) external version during "delivery" is contraindicated for VBAC. So, if he's unwilling to do vagi breech delivery, then I think we should (1) hope B follows her sister out head first; (2) turn her if she doesn't.

Advice? I'm kinda freaking out and of course am pretty pissed that someone else's crappy insurance is affecting my birth choices!!!! Oh, and that's on top of the baggage I have about having babies in the hospital.

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#2 of 42 Old 07-28-2009, 09:24 AM
 
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honestly if it where me I would wait until I was well into labor with baby A almost crowning before going in. But I understand that isnt something you might be comfortable with.

Usually if A is head down most places I know have no problem with vaginal delivery.

 
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#3 of 42 Old 07-28-2009, 09:40 AM
 
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Aww...that's really sad. To have this pulled on you at the last minute.

I don't know what I could do in that situation, sorry.

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#4 of 42 Old 07-28-2009, 11:21 AM - Thread Starter
 
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Usually if A is head down most places I know have no problem with vaginal delivery.
Well, that's what I thought. I'm quite confused. I wonder if calling a different provider with a good track record with VBAC and natural twin birth would be a good idea. Of course a 35w twin VBAC transfer ain't ideal for me, the babies, or a new provider. :

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#5 of 42 Old 07-28-2009, 12:09 PM
 
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I don't know if you'd find anyone else to take you this late. My doctor was fine with breach B, but I ended up with a C-section anyways. If I were in your shoes and the babies came 36 weeks or later, I'd just go in like the PP said, almost crowning. I wish my babies had a vaginal delivery. They both came out with very wet lungs, and didn't have the benefit of steroid shots either. They weren't released from the NICU til almost 38 weeks and I think they could have been better off with the benefit of a vaginal delivery

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#6 of 42 Old 07-28-2009, 01:12 PM
 
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yes, sounds like insurance issue. i would personally go in as late as possible and just refuse intervention unless it seemed necessary. a strong partner is always helpful.

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#7 of 42 Old 07-28-2009, 06:34 PM
 
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Purely anecdotal, but I attended a twin HBAC where the second baby was breech and was turned using external version. Baby B flipped easily once A was out. PM me if you want to know more.

I had a HBAC with my first set of twins and my midwives were not concerned about breech and/or effect on the scar.

Heather, Army wife & Mama to M (10), J (9), L & S (my HBAC babies are 7!), N & R (5), and A (born 11/30/12 UBA2C)
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#8 of 42 Old 07-28-2009, 06:36 PM
 
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Als, I'm sure you know this, but it's not too late for B to turn. One of my twin girls flipped at 36 weeks after several chiro visits using the Webster technique. Don't give up hope!

Heather, Army wife & Mama to M (10), J (9), L & S (my HBAC babies are 7!), N & R (5), and A (born 11/30/12 UBA2C)
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#9 of 42 Old 07-28-2009, 08:30 PM - Thread Starter
 
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I imagine it'd be pretty hard to switch providers at this point. "Luckily" I'll be 36 weeks next week... beyond the point where he can drop me. But it's sounding more and more like this suggestion to RCS for a breech B is not justified, which is what I thought. I'm really surprised, and therefore disappointed, that this would be his recommendation.

I have been working with a WT chiro the entire pregnancy. It's been so helpful for many things. I was way outa wack today - probably thanks to the emotional stress of this. I slept horribly last night.

Unfortunately HBAC isn't a viable option for me - couldn't possibly afford to bring in a traveling midwife.

Ugh, feeling like a caged animal.

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#10 of 42 Old 07-29-2009, 01:08 AM
 
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Is this justified?
It looks to me that you have answered your own question:

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Originally Posted by labortrials View Post
I know that his insurance provider does NOT cover breech delivery. He's been practicing long enough that he used to do breech until his insurance shut him down.
Notice that the above sentences have nothing to do with:
  • your doctor lacking experience in breech deliveries
  • your particular pregnancy/labour
  • the health of your particular babies

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#11 of 42 Old 07-29-2009, 06:31 PM
 
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There is a LOT of good evidence SUPPORTING vaginal breech delivery. Canada recently reversed it's stand on allowing breech vaginal birth in women without other risks. Now, if those risks include VBAC I'm not sure, but I doubt it.

I'm sorry! It's NOT too late to switch and it wouldn't hurt a darn thing to call around and ask.
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#12 of 42 Old 07-29-2009, 10:15 PM - Thread Starter
 
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Intertwined, you KNOW these US OBs don't give a rat's patootie what Canadian docs have decided. "Well that's Canada for ya!"

Novella, good points, but again, how much does that really matter? I live in quite a progressive community, but it's amazing how backassward the birth culture is here. Either you sign up for your epidural (according to the hospital, most women request an epi) or cesarean (our local c/s rate was 31% in 2006), or you're one of those "crazy" homebirthers. But thanks to state regulation, breech & twin births canNOT be attended by registered HB MWs.

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#13 of 42 Old 07-30-2009, 12:21 AM
 
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Also anecdotal but I know a woman who had a HBAC and delivered B breech (A was vertex), Around here it seems that OBs tell us that they are fine with vaginal delivery of A vertex B breech but end up finding a "reason" to schedule a C if they can get you on board. Personally here I think it is because they don't have much experience delivering breech and it makes them nervous....it sounds like your provider has experience though so it is probably an insurance issue. My plan is to wait to go in as long as possible but there is no saying that they won't want me deliver B by Ceserian even if I vaginally deliver A.
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#14 of 42 Old 07-30-2009, 02:22 AM
 
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[Novella, good points, but again, how much does that really matter? I live in quite a progressive community, but it's amazing how backassward the birth culture is here.
Hey there Labortrials, your feelings of futility are palpable and I'm sorry to hear you face such intense pressure as I did to have your healthcare wishes and bodily integrity respected.

"How much does that really matter?" Evidently, quite a bit to you. Otherwise, we would not have seen this post. If you were satisfied with begrudgingly settling for what your OB is serving up, you wouldn't have written seeking advice.

I guess it comes down to which demon you'd rather live with: accepting medical procedures you don't agree with, or having what could be a bitter fight that may continue right through the stress of labour. For me, it was more important to stand my ground and fight for what my husband and I really thought was the best birth, than beat myself up for years that I didn't persevere in that one opportunity I had to do so. You don't get a "re-do" option.

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#15 of 42 Old 07-30-2009, 05:36 AM
 
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I guess it comes down to which demon you'd rather live with: accepting medical procedures you don't agree with, or having what could be a bitter fight that may continue right through the stress of labour. For me, it was more important to stand my ground and fight for what my husband and I really thought was the best birth, than beat myself up for years that I didn't persevere in that one opportunity I had to do so. You don't get a "re-do" option.
ooooo - goosebumps!!! rings true to me to. i needed to know i'd done everything i possibly could to get the safest birth possible - then we have to surrender to outcome or be miserable. but if you're fought to get your rights you're more likely to be in a good mental state after birth than if you've felt abused and your carefully considered choices have been invalidated.


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#16 of 42 Old 07-30-2009, 01:59 PM - Thread Starter
 
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My plan is to wait to go in as long as possible but there is no saying that they won't want me deliver B by Ceserian even if I vaginally deliver A.
Yup, my thought exactly.

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"How much does that really matter?" Evidently, quite a bit to you. Otherwise, we would not have seen this post. If you were satisfied with begrudgingly settling for what your OB is serving up, you wouldn't have written seeking advice.

You don't get a "re-do" option.
The "how much does that really matter" was rhetorical. Well, actually, I'm not sure how much what matters to me matters to "The Tribe."

So true about the redo option. Thanks for reminding me of that!

Anyway, I'm starting to feel more confident about things. My babies are doing wonderfully well, and I trust that B will come out SOMEHOW. My intuition tells me that she'll hold onto her sister's ankles and come out head first. And she has time and room to move.

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#17 of 42 Old 07-30-2009, 02:11 PM
 
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I think the issue is the doctor's liability with a planned vaginal breech. If his malpractice insurance point blank will not cover that under his general policy, it may be difficult if not impossible for him to get a special rider for this one instance. So now he has to consider the liability risk to himself and those that depend on him. If the standard of care for breech B is ECS, and he does not follow that standard of care, he has practically no legs to stand on if there is a bad outcome. I personally try to respect the position my decisions put other people in, but I think you should still go with the plan fits your family the best.
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#18 of 42 Old 07-30-2009, 06:54 PM
 
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So what I don't understand about your doctor -- even a vertex twin B can flip to a breech presentation after Twin A makes his or her exit -- what would his malpractice insurance have him do then? Is this only a problem with how B presents at the start of labor?

It sounds like he's a good doctor -- has breech birth experience and was honest with you about why he can't do a breech birth. Can you talk with him more about what your options are? Will he be honest with you about what will happen in various circumstances? What happens if you refuse to consent to a C-section just because of a breech presentation?

I VBAC-ed my singleton & the hospital where I was originally going to go wanted an epidural in place in case something happened. I didn't want this & in talking it over with the midwife, her advice was to wait until the last minute and go in then. I so did *not* want to do that. Laboring in a car is uncomfortable enough without being in transition in the car, or risking birthing on the side of the road. Can you and your DH rent a hotel room near the hospital and labor there & go in when you're ready, if going in when you're nearly ready to push is an option?

Do you have a doula, and can you get one?

Sending you lots of turn baby, turn vibes!

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#19 of 42 Old 07-30-2009, 09:28 PM
 
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I personally try to respect the position my decisions put other people in. . .
Me too! And the person I would choose any day would be my baby over my doctor.

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#20 of 42 Old 07-30-2009, 09:34 PM
 
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Me too! And the person I would choose any day would be my baby over my doctor.
But I would tell my doctor that I'm sorry he couldn't be my doctor anymore vs. force him to take on a risk he's not comfortable with.
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#21 of 42 Old 07-30-2009, 09:49 PM
 
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Honestly, I think if a mother refuses a cesarean at the time of birth, the doctor cannot be held liable anymore. I mean, he TRIED to get her to do it, right? And although I could see a desperate OB going for a court order, most wouldn't. You might have to sign an AMA form or something along that line, but its not like the hospital can kick you out.

I'd definately try to find out what he'd do in different senarios though. I mean, at the very least he should let you deliver baby A vaginally. The labor is good for both baby's and being delivered vaginally would be better for baby A's lungs. Thats a known fact. If he wont even say ok to that, I dont know what I'd do....I definately wouldnt just sign up for a cesarean regardless though.

*hugs* If I was already a midwife, I'd come help you out!

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#22 of 42 Old 07-30-2009, 10:12 PM
 
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[QUOTE=labortrials;14160177]Intertwined, you KNOW these US OBs don't give a rat's patootie what Canadian docs have decided. "Well that's Canada for ya!"


But, actually they do. It was the Canadian breech study years back that started the whole cesarean for breech all the time with insurance/hospitals/ and docs. That study is how the US Obstetrical community justified changing the policies.



I walked in to a hosp. with preterm twins (planned homebirth) and refused epidural, cesarean, pushing in the OR and a few other things. Did they make it easy- no - but I just kept saying "I refuse consent for that, I am happy to sign a waiver to relieve you of liability." I got everything I wanted. And I did sign some big scary waivers, but I did not care in the least.
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#23 of 42 Old 07-31-2009, 12:59 AM
 
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But I would tell my doctor that I'm sorry he couldn't be my doctor anymore vs. force him to take on a risk he's not comfortable with.
That's all great - when there are other choices available. When I was pregnant with our twins, I phoned and phoned, and asked and asked. I was suggested names of one (perhaps two) doctors who might "allow" the sort of natural birth I was looking for. That was with me willing to travel up to 300 km in one direction and 375 km in the other direction! Certainly, many women in the US live in more populated areas than I do, but current obstetrical conventions can leave the plain just as barren - lots of doctors, but not lots of choice.

Doctors are in service to others. This is just like many other jobs - including any that I've had in my career. Part of that deal means that sometimes your job involves doing things you aren't comfortable with or don't agree with, because it complies with the wishes of the person you are serving.

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. . .but I just kept saying "I refuse consent for that, I am happy to sign a waiver to relieve you of liability." I got everything I wanted. And I did sign some big scary waivers, but I did not care in the least.
(Bolding mine). Thank you for that! The extra sentence about the "big L-word" is a good recommendation.

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#24 of 42 Old 07-31-2009, 01:28 AM
 
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Show me the evidence.


You can birth your baby butt first or head first. And Aile was breech at 39 weeks and came out head first at 40. I would make sure that you DON'T have a version after the first is born. Let the second baby find the way...whether that is butt first or head first.

He needs to present you with solid evidence that shows that having selective MAJOR ABDOMINAL SURGERY is less traumatic and invasive then catching (and not going after) a second baby, with a complete mother.

I am sorry, but that is just crap medicine.

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#25 of 42 Old 07-31-2009, 02:46 AM
 
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Doctors are in service to others. This is just like many other jobs - including any that I've had in my career. Part of that deal means that sometimes your job involves doing things you aren't comfortable with or don't agree with, because it complies with the wishes of the person you are serving.
I disagree. I work in a service industry, and I also have a lot of professional liability. When my customers ask me to risk my neck to provide them with a service that they want that I don't offer, I politely tell them I won't do that, but I can offer them XYZ alternative. It is up to them to decide what is more important, what they want or having me provide them service. I have to consider myself, and the people that depend on me, first and foremost. Sometimes that means disappointing the customers, but I won't risk my ability to provide for my own people because a customer disagrees with me about my professional risk.
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#26 of 42 Old 07-31-2009, 05:07 AM
 
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You can birth your baby butt first or head first.
yeah this. there is so much fear around breech. it is tiresome, disturbing and restricting.

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#27 of 42 Old 08-01-2009, 07:42 PM - Thread Starter
 
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[QUOTE=homewithtwinsmama;14166114]
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Intertwined, you KNOW these US OBs don't give a rat's patootie what Canadian docs have decided. "Well that's Canada for ya!"


But, actually they do. It was the Canadian breech study years back that started the whole cesarean for breech all the time with insurance/hospitals/ and docs. That study is how the US Obstetrical community justified changing the policies.



I walked in to a hosp. with preterm twins (planned homebirth) and refused epidural, cesarean, pushing in the OR and a few other things. Did they make it easy- no - but I just kept saying "I refuse consent for that, I am happy to sign a waiver to relieve you of liability." I got everything I wanted. And I did sign some big scary waivers, but I did not care in the least.
Ah, had forgotten that the initial study came from Canada. I'll definitely mention all of this in case he's "forgotten." Good to know that you were able to get what you want even though it was tough.

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I disagree. I work in a service industry, and I also have a lot of professional liability. When my customers ask me to risk my neck to provide them with a service that they want that I don't offer, I politely tell them I won't do that, but I can offer them XYZ alternative.
Ok, sure I gotcha, but my OB can't provide me with the alternative, not in this town and certainly not at my "advanced" stage of pregnancy. This is an example of UNDUE BURDEN, an actual legal term, that women are consistently subjected to during pregnancy and childbirth.

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#28 of 42 Old 08-01-2009, 07:44 PM - Thread Starter
 
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Oh, and just because you sign a waiver doesn't mean that you can't still sue for iatrogenic damage to mom or baby.

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#29 of 42 Old 08-03-2009, 10:33 AM
 
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I'm sorry I haven't had time to read through the whole thread.

I thought I would share my birth anecdote, although I don't think there were any insurance coverage issues (it's that his malpractice insurance won't cover breech, right?) in my situation.

My twin B had been pretty insistantly breech for the third trimester. He was the larger twin, too, and according to the u/s techs baby A was pretty spread out (even though he was smaller.) I went for some Webster chiropractic sessions (this very successfully turned my first child, who was breech at term) but for whatever reason it just didn't seem likely to work this time around, with a different chiropractor and the particular positioning/space situation.

If twin B was breech when I went into labor, my OB was planning to attempt an external version after baby A's birth.

I went into labor at night on the weekend, and the on-call doctor was not my regular OB. The on-call physician came into the room after we arrived, introduced himself, and recommended a cesarean delivery for the second twin, because he was breech.

At this point, I spoke to him about what my doctor had intended to do, and also said that none of the perinatologists we'd worked with (at a different hospital an hour away) had seemed to think planning a vaginal birth with a breech twin B was outrageous or a bad idea. (I think the policy at that particular hospital would be a breech extraction for the second twin.)

I had a big problem with consenting to an automatic c-section. I said that I wanted to see what happened after the first baby was born....maybe the second twin would turn vertex, given opportunity. If not, maybe assisting him with an internal version would work. Why plan a pre-emptive c-section when we didn't even know what would happen?

The doctor said he wouldn't consider an external version at all (I forget his reasons, but he seemed to think it was a really bad route, despite the fact that his colleague had been planning to attempt one -- I don't disagree with that, actually, and hadn't really wanted my OB to attempt one right off the bat), and he responded to "the perinatologists at the other hospital" bit by sort of poo-pooing their practices (without actually doing so. It was the vibe. Sort of an, "I'm from a little town called Los Angeles, and around there, we think...." wink-wink kind of minimizing of whatever standards were governing protocol in the upstate NY hospital with the perinatologists I'd referenced. Obviously, they weren't as current or up-to-date as those in the little town called Los Angeles....ugh.

In the end, he basically said since I was refusing the c-section, he would do a breech extraction. I don't think we actually got to the point of stating that clearly (I'm pretty sure he was going to return to the discussion with me), because they suddenly realized I was complete and ready to start pushing and all conversation halted. I remember wondering where we stood, but after the first twin was born I heard him tell someone he'd agreed to a breech extraction.

So he was preparing for the breech extraction but the baby turned, instead. (I was upright when the first twin was born, so I took a good bit of time turning around, getting down, and getting into position for the extraction. All the while, I was telling my baby A how to turn, which I'd been doing for weeks at the end of the pregnancy, too. But at that point, it was "Now's the time, baby! Head down, facing back, chin to chest.") There was very little the OB had to do to turn him, though I think he reached in and helped in some way (I didn't feel anything at all, but I asked when I saw the doc a few days later and he said, "I turned him." But he also mentioned that the baby was turning, and he "reached in and turned him" so I think whatever happened was not heavy-duty wrangling.)

Anyway, I'm sharing this because I had an ostensibly "current" doctor (in town, he's considered the "young, up-to-date OB who is very competent but not always the best with his bedside manner") who spewed all sorts of studies findings contraindicating versions & extractions, and was recommending automatic c-section for the second breech twin.

I don't think your doctor is necessarily coming from nowhere with this.

As far as hospital policy, they don't do breech deliveries. With multiples, if the first twin is vertex, the "vaginal attempt" is "allowed" but I think the second vaginal birth only will happen IF the second baby turns. (Unlike the other hospital I mentioned, where breech extraction is standard.) With my regular doctor, though, if the second twin could not be turned, she would have opted for a c-section (she never offered me a breech extraction or any kind of breech birth.)

I had gone into it believing my baby would turn when he had the chance (I honestly didn't believe the external version was going to be needed and I think I'd have asked her to wait, though not sure how that would have all gone down), and not thinking that I would end up with a c-section. But I guess I knew if things went wrong or he just didn't turn, or if he got into a stubborn transverse presentation or something, c-section would be the result. In the end, I think the on-call OB was assuming breech extraction as the default, probably because I had refused a c-section (at least, a planned one) and it was so late in labor that maybe they could claim a breech extraction was unplanned? Or that it was done only because I refused the other procedure?

I'm sorry I'm rambling so much.

I wonder if your doctor would consider making the decision after the birth of the first twin, when he can see what happens with the second twin's positioning. You may not be able to push him to deliver the breech twin, and he may not reconsider his misgivings about external version or internal version, but maybe you could clarify that rather than an elective repeat c-section, you would like the decision made in the moment because of necessity ("necessity" in this situation, of course, being debatable) rather than planned from the start. Perhaps the baby won't need a lot of manipulation, or any manipulation. You understand his policy against breech delivery, but is he willing to consider any alternatives or allow that there are possible scenarios that would make a c-section completely unnecessary?

(Sorry if you've already gotten past this point and are no longer dealing with him. Like I said, I didn't read to the end of the thread.)

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#30 of 42 Old 08-03-2009, 10:37 PM - Thread Starter
 
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Thanks Amy (and everyone!). I appreciated reading your story. I see my OB again tomorrow and will ask him where we go from here if B is breech. My preference is to take a wait and see approach. At this point I see little point in switching providers. I'm not even assured to have my doc (or a doc supportive of vaginal twin or VBAC) staring into my yoni when it comes time. :

I know he's not coming from "nowhere" on this breech stuff, but ACOG's resistance to breech birth is based on a faulty study from Canada in 2000. Luckily Canada is reversing its position on breech birth. Yes there are studies that claim that versions (internal or external) are contraindicated, but really a LOT of this stuff is in that murky controversial state.

My chiro thinks B's butt is up in the top of my uterus. Hope that turns out to be the case. I'll be meeting with my OB tomorrow - wish me luck!

Kimberly, mom & wife - blogging.jpg about pregnancy and birth
DD 2004; 3 angel1.gif babies 2007-08; rainbow1284.gif twin DDs 2009; DD 7/12/11 hospital uhoh3.gif VBAC bouncy.gifafter 2 cesareans!

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