Twins! Breech! Stat!

After sleeping (well, on and off) most of the night last night (my luck was good to me!), I woke up to hearing this overhead:

"Team to the OR. Twins! Breech! Stat!"

I wandered out of the call room towards the OR, blearily wiping the sleep from my eyes. I arrive there to find chaos. "Does she have an IV? No IV?" said the anesthesiologist.

I said, "What's the story here, guys?"

The resident in triage said, "I don't know, I didn't get a chance to talk, but the triage nurse says she's complete (i.e. fully dilated), ~32 weeks, with twins, first one's breech".

The intern says, "Looks like the first one's vertex to me."

By that point, I had gloves on, but no gown. I say, "OK, everybody, take a deep breath. Intern, do we have heartbeats on both babies?"

Intern says, "I can't find the body of A, but baby B's in the 150's"

I check the patient.... is that a knee or is it an elbow. Hm... move down the limb... Oh, it's a foot. Oh, and there's another foot.

Patient has a contraction. Intern is saying, "Don't push, don't push.". Now, when you're complete and have a baby in the vagina, you have a reflex where you will push when you have a contraction. It's as much a reflex as breathing. Your body knows how to have babies. Most people, especially if they don't have an epidural, can't not push in that situation.

So, the feet, knees, thighs, and scrotum of the first baby deliver. I say to the woman, "Oh, so your first baby's a boy! Any problems with the babies?" (at this point I was wondering if this was a bizarre dream) The woman says, in a gutteral tone, "Nooooo".

So, my next move may or may not have been the right thing to do. We've (not me, I was still in gradeschool) been doing c-sections for double footling breech babies since the early 1980's. The problem with the footling breech is that with the hips extended, the diameter of the breech isn't large enough to obstruct the pelvis completely. The problems with that are 2 fold. The first is that the umbilical cord can easily prolapse, and that is a huge problem. The other problem is that below 34 weeks or 1500 grams, the intertrochanteric diameter of the fetus is smaller than the head. That means that with a footling breech presentation, especially, the hips can deliver through a cervix that isn't dilated enough to allow delivery of the head.

The other problem, related to the situation, was that we had no idea what baby A's heart rate was. The reason the intern thought the baby was "vertex" but couldn't see the body was that it was breech with the body in the vagina, so the only thin in the pelvis for the intern to see was the head.

The other problem is that once the baby's partially delivered, you've passed a point of no return, where in all likelihood, the probability of fetal damage (sometimes just bruising, sometimes fractures, sometimes cervical spine injuries) is high if you try to push the baby up into the uterus for a c-section.

However, the problem with a breech extraction (instead of an assisted vaginal breech delivery) is that you can startle the baby, cause it to moro, and end up with a nuchal arm, which can be difficult to reduce, and I have, once broken a humerus attempting to deliver a baby with a nuchal arm. (Although it sounds bad, apparently baby bones heal really well... that baby did fine, delivered, no permanent injury). With an assisted vaginal breech delivery, you have the mom push the baby out until it's delivered to the level of the scapulae, and then you sweep the arms, flex the head and have a baby!

Remembering my obstetrical history and lore, I remembered that footling breech=breech extraction because of the risk of cord prolapse, which can be occult (unseen), and that all other breeches (of singletons or first twins)=labored assisted vaginal breech delivery.

So... I pulled the rest of the baby out, swept the arms, flexed the head, and handed him off to the neonatologists, pink and screaming, APGARs 8/9. Now, I do wonder if, with a small baby (wt ended up being 1300gms, a little smaller than the usual lower limit for a vaginal breech, but the baby decided to come that way anyway), and first twin, if at that point, it might have been better to have the mom push the baby out (i.e. assisted vaginal breech); but I'm not sure.[1]

Remember, at this point, I still had gloves on, no gown. The intern (who needs to be taught how to scan twins... this is not her fault!), said, "Oh, second baby's vertex!". Then I breathe, and decide to relax.

And I go to check and feel for the head, and realize I have my arm in the patient's vagina up to the elbow with no gown. I turn to my chief resident (the one who caught my forceps mistake earlier), see that she's gloved, gowned, and ready, and I say, "Chief, can you deliver this baby for me, this is kinda gross [referring to my icky vaginal goo and blood coated bare arm]?".

Chief says, "Sure, no problem." Did I mention that Chief had practiced obstetrics in her home country for 16 years before emmigrating to the US? She's got more Ob experience than I do. It's great being on call with her.

Chief says to me, "Um... the baby's transverse spine down, I can't get a foot, we're going to need to do a c-section."

Now, it just seems stupid to do a vaginal delivery of a breech first twin, and then to do a c-section for the second twin. I would really feel like the fetus had defeated us.

But, there's no time for me to put on a gown. Morbidity and mortality in second twins seems to be proportional to the time between the delivery of the first twin and delivery of the second twin. The longer you wait, the more likely it is the second twin will have problems.

So, if you're going to do it, you do it now.

So, I put my arm in, found a foot, performed an internal podalic version (turing the baby to breech from inside the uterus), and pulled the baby down.

Problem.

This baby is twice the size of the first.

But I've already pulled it down. We're past the point of no return. F*&#!!

I do have a backup attending on call with me. That attending covers most of the gyn stuff, and I do the obstetrics. I did remember that the attending had grey hair and a southern accent, which made me suspicious he had done a breech or two in his lifetime. I say (?yell?), "Call Dr. Attending, and ask him to come to the hospital and meet us in the OR." Thinking that if the baby's not out by the time Dr. Attending gets there, then we'll really need him, but it would be too late to call him.

But the second baby came out just fine. Pull the feet... pull the hips....blue towel (babies are slippery!)... pull the body, thumbs parallel to the spine so as not to twist it... watch the adrenals (both the baby's and mine!), sweep the first arm... sweep the second arm... flex the head... baby on mom's tummy.

Breathe.... breathe... breathe.

The result? Baby A boy, APGARs 8/9, wt 1300gms, Baby B girl, APGARs 8/9, wt 2400 gms. Both now screaming in the nursery. The girl will probably get to go home with mom (if feedings go well), the boy will have to stay for "gaining and growing".

A happy little family.

A mom glad that she didn't have a c-section.

High fives with the residents, nurses. Hugs from the patient and her husband. Is it bad to high-five at a birth?

I like breeches. I'm good at breeches, in general. I've probably done 30-40, which is more than most practicing obstetricians.

I'm just not good at teaching them. I get a little too nervous. I should have let Chief deliver the baby once I'd pulled the feet into the vagina. But, I was a bit scared.

So, all in all, a happy ending, but I still need to work on being more able to turn the reigns, even on the tough cases, over to the residents.

It's just that I've been out of residency less than a year, so I'm not quite as confident as I could be, sometimes, and I still worry. Sometimes a lot.

But vaginal breech delivery is a good skill to have, because people do show up too advanced in labor for a c-section, sometimes, and it's important to recognize it and be able to make quick decisions about it. You don't want to injure a baby worse trying to push it back up into the uterus to do a c-section. You don't want to cause unnecesary fractures [2] because of a lack of skill with a breech delivery. It's a conundrum, because the vaginal breech is a dying art. But it's a problem that's not going to go completely away, because there's going to continue to be a need for it, however infrequent. It's not a terribly difficult procedure, the maneuvers are technically easy, it's the decision making that's hard, and the decision making requires experience. And experience, for the residents and for their future patients who arrive with feet and scrotum hanging out of their vagina, requires me to calm down and let the residents do it.

And I'm one of the few docs who still will do vaginal breech deliveries. So if I don't teach it, who will?

(Pictures gratefully stolen from Birthing Way)


[1] Note to self: Find an old attending who has done breeches for a long time and ask him/her what they think.

[2] There are necesary fractures. The fracture of a humerus to release a head entrapment due to a nuchal arm. The intentional fracture of a baby's clavicle to allow delivery in a severe shoulder dystocia (which I've only ever done twice, it's a terrible feeling, to break a baby's bone on purpose).