VAGINAL BREECH DELIVERY

1
Breech Vaginal Delivery
Michael L Hall MD Englewood Colorado
2
Breeches occurs naturally in nature
3
Most come head on
4
4 are breech
5
CRITERIA
6

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500

Gabbe Obstetrics
7

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH

8
(No Transcript)
9

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH
• ADEQUATE CLINICAL PELVIMETRY

10

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH
• ADEQUATE CLINICAL PELVIMETRY
• MILITARY FLEXED HEAD

11
Star Gazing Hyperextension of head
12

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH
• ADEQUATE CLINICAL PELVIMETRY
• MILITARY FLEXED HEAD
• FOLLOW FRIEDMANS CURVE

13

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH
• ADEQUATE CLINICAL PELVIMETRY
• MILITARY FLEXED HEAD
• FOLLOW FRIEDMANS CURVE
• NORMAL FETAL MONITORING

14

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH
• ADEQUATE CLINICAL PELVIMETRY
• MILITARY FLEXED HEAD
• FOLLOW FRIEDMANS CURVE
• NORMAL FETAL MONITORING
• EXPERIENCED OPERATOR SKILLED WITH FORCEPS

15

• CRITERIA
• EFW 2000-3800 GRAMS 2500-3500
• FRANK OR COMPLETE BREECH
• ADEQUATE CLINICAL PELVIMETRY
• MILITARY FLEXED HEAD
• FOLLOW FRIEDMANS CURVE
• NORMAL FETAL MONITORING
• EXPERIENCED OPERATOR SKILLED WITH FORCEPS
• INFORMED CONSENT

16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
LOOP OF CORD
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
OR FINGER FORCEPS
29
(No Transcript)
30
(No Transcript)
31
Pipers
32
(No Transcript)
33
(No Transcript)
34
Low one minute Apgars not uncommon Have Peds
present
35
(No Transcript)
36
DONT DO THIS AT HOME
37
(No Transcript)
38
32 year old G4 P3 arrives in Labor and Delivery
in the wheelchair from the emergency room
obviously in transition. Placed into the bed and
upon inspection, feet are hanging out--- What do
you do???
39
Footling Breech
40
The OR is in use TWINS
41
Anesthesia is staring at you!
42
The head nurse is staring at you!!
43
Anesthesia is sweating--
44
The patient is screaming for you to GET IT OUT
What do you do?
45
Take a deep Breath
46
Take 30 seconds to take in the sceneryassess
the pelvis, check for a cord, send someone for
the pipers! and peds
47
Anesthesia is still staring at you
48
Tell her to PUSH!!!!!
49
Apgars 8 -9
50
So Whats the Problem??????
51
TERM BREECH TRIAL COLLABORATIVE GROUP Planned
caesarean section versus planned vaginal birth
for breech presentation at term a randomised
multicentre trial. Mary E. Hannah et al. The
Lancet. Vol 356, October 21, 2000. pp1375-1383
52
The term Breech Trial aimed to provide
evidence-based guidance on the controversy as to
the preferred mode of delivery of breech babies.
53

• 121 Centers
• 26 countries
• Almost immediately, conclusions accepted by the
  medical community
• Profoundly changed medical practices around the
  world

54
Five years to the term breech trial the rise
and fall of a randomized controlled trial. Marek
Glezerman, MD. Am J OB-GYN (2006) 194,
20-5. Conclusion The original term breech
trial recommendations should be withdrawn. Dr.
Glezerman was chairman of one of the
participating centers that contributed patients
to the trial.
55

• Lack of adherence to inclusion criteria
• Interinstitutional variation of standard of care
• Inadequate ante and intra partum fetal assessment
• Many women recruited in labor
• No attendance of a clinician with adequate
  experience

56
Inappropriate use of randomised trials to
evaluate complex phenomena case study of vaginal
breech delivery
Andrew Kotaska, BMJ 20043291039-1042 (30
October),
57
The Parachutes and Gravitational Challenge
58
Evidence-Based Medicine Opportunities for
Future Study

• Parachute use to prevent death and major trauma
  related to gravitational challenge
• Study design
• To determine whether parachutes are effective in
  preventing major trauma related to gravitational
  challenge
• Systematic review of randomized control clinical
  trials
• Medline, Hanna Databases, etc.
• Death or major trauma

59
Evidence-Based Medicine Opportunities for
Future Study

• Conclusions (cont)
• We think that everyone might benefit if the most
  radical protagonists of evidence-based medicine
  organize AND participated in a double blind,
  randomized, placebo controlled, crossover trial
  of the parachute.
• Smith GC, Pell JP. Parachute use to prevent death
  and major trauma related to gravitational
  challenge Systematic review of randomized
  controlled trials. BMJ, 2003 Dec
  20327(7429)1459-61.

60
Evidence-Based Medicine Opportunities for
Future Study

• Findings
• No Studies identified meeting criteria
• Conclusions
• As with many interventionsthe effectiveness of
  parachutes has not been subjected to rigorous
  evaluation
• Advocates of evidence-based medicine have
  criticized the adoption of interventions
  evaluated using only observational data.

61

• The Term Breech Trial failed to appreciate the
• Complex nature of vaginal breech delivery
• Complex mix of operator variables necessary for
  its safe conduct

62

• Statistical power required a high vaginal
  delivery rate
• So, researchers encouraged practitioners to go
  beyond their comfort level
• Comfort level difficult to quantify
• Comfort level plays a pivotal part in safety of a
  complex procedures
• Practitioners were protected from medical
  liability
• Practitioners pushed their comfort levels
• This constituted a significant BIAS One of
  license
• Protocol allowed for .5cm/h dilatation and 3.5
  hours for second stage
• Few obstetricians with proved safety in vaginal
  breech delivery would find them acceptable

63
Widespread acceptance of this trials results has
breached the limits of evidence based medicine.
64
A major limit of evidence based medicine is the
difficulty in applying the results of randomised
trials to individual patients.
65
-multip -38 weeks -advanced labor -3000
grams -flexed head -no nuchal cord ----low risk
sub group
66
Now, experienced Obstetricians will press for an
emergency cesarean section, not trusting their
clinical judgment because all breeches are
assigned a similar risk status by a randomised
controlled trial.
67
Vaginal Breech Delivery
A Discriminating Procedure
Human skills vary Delivery technique is an
ART
68

• The safe vaginal delivery requires skill in
  multiple arenas
• Delivery Technique
• Use of forceps if needed
• Ultrasound assessment
• Selection of cases not everyone is a candidate
• Intrapartum fetal surveillance
• Conduct of labor
• Pediatric support
• A coordinated, well functioning labor and
  delivery unitBE PREPARED

69

• Summary Points
• When applied to complex phenomena, randomised
  trials have important limitations

70

• Vaginal Breech delivery is a complex procedure
  that is poorly amenable to the methods of large
  multicenter randomized trials.

71

• ONE randomised controlled trial has dictated a
  new standard of care for vaginal breech
  deliveries worldwide

72
The use of a short term combined end point
overstated any true risk of planned vaginal
delivery to longer term neurodevelopmental outcome
73
TWINS
TWINS
74
GET EXPERIENCE WITH LOTS OF BREECHESBut
VBAC
75
(No Transcript)
76
Think
77
Dont Flail
78
THE END