Heads Up! Breech Conference
November 9-11, 2012
Michael Hall: Tips & techniques
November 9, 2012
Dr. Michael Hall has lived through several major shifts in obstetric practice. When he trained several decades ago, he learned all sorts of skills that are dying out-vaginal breech, forceps, and more. They didn't do c-sections for breech. Everyone did VBACs; it was actually a requirement for a period of time. Then he lived through a huge shift in practice where almost everyone had c-sections. Now he's seeing the pendulum swinging back toward keeping vaginal skills (forceps, breech) alive. He passes his skills on to the students he trains, but he just doesn't have the population base to train enough people at his own hospital. That's why he has since set up a breech unit at the local university hospital.
Dr. Hall's selection criteria for VBB:
- Because he uses pretty strict criteria, it's kept him out of trouble. Physician colleagues who've gotten burned with breeches often have done things outside of a reasonable criteria.
- EFW 2000-3800 g
- Frank or complete breech (he's found that complete breeches have a larger bottom diameter and thus the head is easier to birth than with a frank breech)
- Adequate clinical pelvimetry: do a good pelvic exam; you'll know by experience if a pelvis is small or abnormally shaped
- Flexed head (i.e., no hyperextended head)
- Follow Friedman's curve: for a breech, you want a normal, consistent labor pattern. The ones that slow down make him nervous. For induction or augmentation, he never goes above 6 ml/u, which is what simulates a normal labor pattern. You don't push your limits in a breech. Once they're in labor, he usually turns the Pit off.
- Experienced operator (skilled with forceps). He's only had to do it 4 times in 31 years with hundreds of breeches. It's a last resort, but an important skill to have.
- Informed consent. The biggest thing (he wants the husbands to be aware of especially) is that sometimes babies are breech for a reason and will have problems no matter the route of delivery.
The way to birth a breech is to leave it alone. He has the mother do all the work. You have about 4 minutes to get the baby out once it's born past the umbilicus, unless the baby still has blood circulating through the cord. He rarely helps reduce the legs; they almost always do it on their own. If you get a nuchal arm, you need to know how to help the arm come down. Most of the arms will come on their own if you let the mother push the baby. That takes patience and sitting with your arms crossed! You have do things gracefully. If you're struggling, you're doing it wrong. Keep the baby in line. Be firm but gentle. The mother can push the baby out in line; we're the ones that take it out of line. (By "in line," he means never move the baby or the head laterally. You want the spine and the head to always be in line with each other.)
In certain cases he does "finger forceps" (deep perineal massage). He thinks this helps the head emerge more easily. He also thinks it helps women push better if they're having trouble focusing their efforts.
He's never used Mariceau-Smellie-Veit much himself. He has 2 other tricks to get the head out:
1. Have someone lift the baby up slightly to do finger forceps. Put your fingers inside and stretch and pull to make more room for the head to come out. You have to get in deep and push down on the leveators. What's important is that downward descent: even an extra ½-1 cm will make all the difference
2. Apply gentle suprapubic pressure to ease the head out gently.
When the head is emerging, avoid over-extension of the baby's body (if the mother is on her back). Sometimes babies can aspirate matter as their faces emerge. Keep an eye out for that. Pipers forceps are no more difficult than an outlet forceps. If it's a struggle, you're doing it wrong. You slide the lower blade in first. He always keeps them ready, even though they are rarely necessary. Follow the curve of the pelvis with the blades. He's never had a head get stuck that wouldn't come out. Do an ultrasound before labor and check for hydrocephalus or other neurological issues. Know your patients.
Low 1 min Apgars aren't uncommon; have Peds present.
He's seen some prolapsed cords--2 in the last 50 breeches.
He tells all his women planning VBB that they have to exercise and work out. They need to be in shape so they will have the endurance to birth their babies.
Hands and Knees:
After the last conference, Dr. Hall started doing H&K births. He finds them a whole lot easier than on-the-back breeches. You do much less maneuvering on H&K.
The baby comes out Sacrum Transverse. It then rotates to face you (Sacrum Anterior) when the woman is on H&K. The butt goes straight down and gravity helps it emerge. The baby will reduce its own legs. After that point, gently check the cord to see if there is still blood flow. At this point, strongly encourage the mother to push. Do not pull on the baby. Remember: push, but not pull. The arms will usually come out on their own. After the baby is out to the shoulders, here's another trick: take gentle thumb traction and put it on the clavicles, then press directly backwards. This flexes the head. (This is also known as "Frank's nudge." Some people apply subclavicular pressure; others apply it to the shoulders.) You push straight back on the clavicles, not pull down. Be gentle.
His very first experience with breech was during an externship; a woman came in and delivered a breech on the way to the delivery room while everyone else but him was gone scrubbing in. It went really easily and set the course for his attitude about breech.
What if...real life situation...a 32 year-old G4P3 arrives in L&D in transition. Upon inspection, you discover feet hanging out. It is a double footling breech. What do you do? The OR is in use with twins. Anesthesia is staring at you, expecting to do a crash section. The head nurse is staring at you; she does NOT want a crash section. The patient is screaming for you to "take it OUT!" Anesthesia is still staring at you. What do you do?
Take a deep breath. Take 30 seconds to take in the scenery (assess pelvis, check for cord, get the Pipers, get Peds). Tell her to PUSH! If they're coming that fast, they'll probably be fine. Doing a crash C/S often will do more harm then going ahead with a vaginal birth in this situation. The nurse came up and thanked him afterwards: "That could have been a disaster."
You have to be comfortable working with breeches; you also need to be smart.
Term Breech Trial
He discussed the TBT quickly, because it will be covered in other sessions. He's seen so many pendulum swings during his career that it's not even funny. He's always just kept on doing breeches. He discussed the current situation in the US, the recent ACOG recommendations, and problems with the TBT. Evidence-based medicine in obstetrics is just about impossible to do; most things are observational. The TBT failed to appreciate the complex nature of VBB and the complex mix of operator variables necessary for its safe conduct. VBB is operator dependent; he doesn't let some of his residents do it because they're klutzes! The safety of vaginal breech is dependent on the skill level of the attendant. The most difficult part is determining when you need to do something and how fast to do it. You have to move "deftly." You have to know when to move and when not to move. Those issues cannot be randomized. The TBT had many issues complicating the study, pushing practitioners beyond safe limits. The reason that an experienced OB won't do a breech-even one that's as picture perfect as you can get--is liability reasons.
The ACOG's current guideline on breech states: If you're experienced, it's OK. The guidelines also note that we are not training OB residents in forceps or VBB. Those skills are becoming a lost art.
Safe vaginal delivery depends on skill in multiple areas :
- Delivery technique
- Use of forceps
- Ultrasound assessment for presentation, head flexion, & major anomalies
- Selection of cases-not everyone is a candidate
- EFM during labor
- Conduct of labor
- Pediatric support
- A coordinated, well-functioning L&D unit; be prepared
He does breech-first twins. A study concluded that if the operator is experienced, then a vaginal birth of breech-first twins is a safe option.
Above all, you need to think. You can't just say "it's a piece of cake." Most of them are, to be honest. But always keep a sharp eye out for odd things.
Women want choices.
Q: If the baby is not directly SA, do you rotate the baby?
Q: Can you tell us about difficult breech scenarios?
To answer these questions, Dr. Hall showed two breech videos from his practice. The 2nd video showed a baby with nuchal arms; the mothers was on H&K. After the baby's body emerged, it did not rotate back to Sacrum Anterior. Instead, it remained around 45 degrees from SA, indicating one or more nuchal arms. You reach in with the hand that's towards the back and gently push/sweep it across. If it's not coming easily, you probably need to get some other position. If the other arm is still trapped, you can rotate the baby 180 degrees; the arm will often come out on its own. Then you rotate the baby back to SA. When a mother on H&K drops her chest or lowers her bum, the pelvis opens naturally. The baby often lifts its legs up and flexes its own head and comes out on its own. If that doesn't happen, gently push on the clavicles with your thumbs to flex the head. If you're having trouble, have the mother lower her butt towards you. His H&K deliveries tend to come out so fast they fall out; his nurses are getting really comfortable doing them now.