Delivery

December 14, 2007

It was in the old days (circa 1979). The residents at Charity Hospital had been notified that all but the most crucial of power sources would be out while Maintenance did some electrical work. We had been delivering babies by flashlight, the better lighting reserved for surgical suites. We were good, well-trained--starting IVs by feel, running Labor and Delivery in the shadows without missing a beat. Childbirth went on in the non-air conditioned, unlit labyrinth of the 10th floor of that great grey building on Tulane Avenue. Now try to imagine, if you will, the tense scene that day.

I sat in the delivery room, waiting. My patient was completely dilated and pushing, her baby moments away from breathing room air instead of umbilical cord exchange. I prayed, though, that it would be that simple, for the patient had had a C-section two years earlier. She had arrived unannounced, with no prenatal care, ready to deliver. There was no time to prepare for a repeat C-section. "Once a C-section, always a C-section," played through my head according to my training. I feared the force of expulsion that normally results in a delivery would tear the old scar in her womb (uterus), creating a hemorrhagic crisis for baby and mother. "Please don't rupture," I prayed. The nurse bit her lip as I uttered the words. It was melodramatic to say the least.

It was so silly, as it turned out.

At that time, soon-to-be published studies would confirm earlier research that concluded that vaginal birth after cesarean (VBAC) was no more risky than any vaginal delivery. It's funny how times have changed.

C-Section Costs-Enter capitalism.

Looking to lower hospital costs for maternity services, managed care--HMOs, PPOs, and several other letter combinations-- welcomed the fortuitous results of the data, validating their push to lower C- section rates. The first immediate tier of the rate that could fall was the repeat C-section rate. VBAC was here to stay. Now openly encouraged, a specialist from twenty years ago would wonder if we were out of our minds. And now there are studies investigating vaginal delivery after more than one or two C-sections.

If you listen carefully, you can hear the squirming of even the most holistic of yesteryear's midwives.

Even with the overwhelming evidence exonerating VBAC as completely safe, many patients still choose, even insist upon, repeat C-section. They fear a long fruitless labor, only to resort to surgical delivery anyway. They may want a scheduled birth, instead of the uncertainty of the onset of labor, which may not come for weeks after a scheduled C-section. They may fear that an uneventful C-section recovery may be easier than recuperating from a very difficult vaginal delivery. These are real concerns, and even though I encourage and favor VBAC, I still feel it should be the patient's decision. As long as she realizes that the infection and transfusion rate is ten times greater (although rare in private practice), she is qualified to take part in the decision. But soon, the decision will be made by what managed care says they will and won't pay for. This time, however, capitalism may be right.

C-Section Rates Will Be Lower

One of the hottest issues in Obstetrics today is the high C- Section rate. Percentages anywhere from 17% to 35% are quoted as the likelihood that an expectant mother may have this route of delivery for her child. Many factors have contributed to this in the United States. Certainly a doctor's legal fears of a bad outcome have made the rates higher. But doctors often misdirect their distrust of lawyers. Upon closer examination, practicing good medicine is really the same thing as practicing defensive medicine, because not having a reason to be legitimately sued means a good outcome, and this is always in the baby's and parents' best interests. What seems like professions at odds is really nothing more than everyone being on the same side. Of course, I'm only talking about claims of merit, and reputable attorneys understand this and object to frivolous lawsuits. But while wanting good outcomes has driven the C-Section rate up, there are many factors that will drive it down in the next few years.

Many women are and should be offered vaginal birth after Cesarean (or, VBAC). This will bring down the repeat-C-Section rate dramatically, since the adage, "Once a C- Section, always a C-Section," is no more valid than an old wive's tale. One of the biggest contributors to the C-section rate is the population of women with previous C-sections. VBAC is designed to impact this repeat phenomenon. Of course, the way to prevent "previous" C-sections of tomorrow is to avoid first C-sections in the present.

Delays in administering epidurals until labor is well established will allow the baby's head to descend into the birth canal at the correct angle, preventing the labor from being "hung up" and make less likely a C-Section for failure of the labor to progress. The field of Anesthsiology has countered the delay in this valuable form of pain relief by developing something called a "walking epidural." This can be given before 5 centimeters dilatation without tripling the risk of ultimate C-section like the standard epidural does if given that early.

Inductions, while useful and often indicated, should be carried out with certain guidelines. If the mouth of the womb (cervix) is not inducible, the labor may not be effective. A C- Section may seem necessary, when waiting for a more inducible cervix may have made a vaginal delivery more likely. Of course, some medical complications make induction mandatory before its time, but these are situations that can't be helped (rupture of membranes, for instance). Also, some physicians are stretching the definitions of ineffective labor. Whereas no dilatation over two or three hours may be the hallmark of a failed labor, sometimes a gut feeling will allow a doctor to let the labor go on for some time after, as long as the baby's heart rate is excellent.

Now that insurance companies are actively seeking ways to cut the cost of medical care, obstetricians are being invited to cooperate with ideas like the above or face not being included on provider lists. Even though this can be unfair, because every case is an individualized case and not something to fit into a formula, still the aim is a good idea. And it has been proven that just talking about ways to bring down the C-Section rate has in fact caused a reduction.

In this country, we may not be able to bring our rate down to that of a homogeneous society, like in Ireland, for instance, but we can certainly try the simple things first and expect an excellent start. It's bound to happen.

Breech Birth

Breech position means that the unborn baby is not head-first. The most common type of breech position is "frank" breech, in which the infant's buttocks are the first to descend into the birth canal. His or her legs are flexed at the hip, pointing the legs, straight at the knees, up toward the head. In contrast, a footling breech has the knee or knees flexed, such that the feet join the buttocks as the presenting part. This type of delivery can't be done vaginally--geometry will not allow it to go smoothly. A frank breech, on the other hand, can deliver vaginally, the buttocks alone acting as an efficient dilating wedge much like the head would.

But the statistics on delivering breech babies vaginally are a concern. Assuming of course the delivery was frank breech, the statistics say there is still an increase in the number of babies born who may suffer from "soft" neurological complications. This is even when everything seems to have gone well. Besides an increased risk of obvious trauma, soft neurological complications often go unnoticed but haunt parents later as hyperactivity, attention deficit disorder, dyslexia, and a host of other problems. I must point out, however, that some challenge this thinking.

Cesarean delivery is now recommended as the safest approach to seeking the best outcome for these babies. This is not to necessarily avoid soft neurological complications; this is done to avoid a most feared outcome in delivery--all of the baby being able to deliver but the biggest part--the head!

You could imagine.

We must consider, however, the increased risks to the mother that come with cesarean section. It's true that the complication rate in private practice is low, but it's still higher than with vaginal delivery. So the answer seems to lie with talking these little babies into assuming a head-first presentation.

That sort of diplomacy is called External Cephalic Version, a technique in which the baby is actually turned to the head-first position. We used to do this blindly at Charity Hospital, a forceful procedure involving two physicians, one pushing against the mother's abdomen, the other doing a pelvic exam to exert pressure there. This fell into disfavor because mothers really weren't crazy about the technique, and there seemed to be a feeling that there was probably a pretty good reason for the baby to be breech in the first place.

There is now newer thinking on the subject. The reason why version in the past failed often was that the patients who were scheduled for version weren't selected very well. Now, criteria such as how low the breech baby is and where the back is placed in the womb have made version safe and for the most part successful. Ultrasonographic guidance and gentle manipulation, while a drug that relaxes the womb is used, have made the procedure desirable once again. Add to that the need to bring down C-section rates and suddenly it begins to make a lot of sense. What has happened is that the old procedure using blind force against any breech baby has been replaced with a gentle maneuver done with a relaxed uterus under ultrasound in well-selected patients. It's called look before you leap, and it's an advance in that it's an improved rediscovery of an older procedure. It won't be the last time doctors fall head-over-heels for a safer outcome.

When a Baby Throws a Shoulder Block-Shoulder Dystocia

One of the most frightening complications during a delivery is shoulder dystocia. This is when the infant's shoulder girth is too large, causing the baby to be "stuck" in mid-delivery, the head out but the shoulders wedged in. In this position a sort of point of no return has been reached, as the umbilical cord may be compressed by the chest and shoulders of the undelivered baby. And with the chest compressed by the vaginal walls, the baby can't expand the lungs to move air.

Back in the olden days--that is, just a few years ago-- shoulder dystocia frequently resulted in injury to the infant. Nerve paralysis, brain damage, as well as the subtle outcomes of oxygen deprivation could follow a difficult birth that involved this complication. After traction in different directions, complicated cork-screwing maneuvers were next in the sequence of attempts to finish the delivery. The clock would keep ticking. The baby's clavicle, a flimsy bone of the shoulder, would give way either by accident or by design so as to make a collapsible escape for the respective shoulder. The scene was tense for all of the right reasons.

McRoberts Maneuver

Now we use a technique called the McRoberts maneuver.

In this technique, the woman's thighs are pulled far back onto her abdomen while an assistant applies pressure downward right above the pubic bone. The maneuver of the thighs causes the pelvic ring to increase in size, and the pressure on the baby's shoulder from above the mother's pubic bone forces it out toward the doctor who is pulling with an additional force. Most often these babies are delivered within a moment of recognizing the problem. It's hard to give credit to this maneuver to the extent that it deserves. How many injuries or even deaths have been prevented would be impossible to tabulate. This uncomplicated technique is a powerful reminder that for all of it's intricate biochemical processes and miraculous genetic unfolding birth is still a process of mechanical simplicity.

Shoulder dystocia is a risk factor that every large baby has. The obstetrician knows that the chances of it occurring are increased with a history of previous shoulder dystocia, a history of large babies, or diabetes. Since the head is thought to be the largest part to deliver, with the rest of the baby supposed to follow thereafter, shoulder dystocia often comes as a surprise. But there are subtle signs that can tip off the obstetrician. Slow progress of labor (dilatation of the cervix) or prolonged descent of the baby's head down the birth canal should caution the doctor not to "help" the head out with forceps. This may in fact invite a shoulder dystocia, and no vaginal delivery at all would be preferable. A C-section, although second choice, is better than the victory of a vaginal delivery at the expense of one's child. The McRoberts maneuver works well. There may still be a broken clavicle from time to time, often found incidentally after delivery, but the laws of physics are used to advantage to prevent terrible outcomes in what used to be one of the most feared complications of childbearing.

(Additional note: I have a colleague who is currently being sued for applying the McRoberts maneuver in a VBAC delivery. He saved the baby's life, but the force used opened her previous C-section incision. She eventually needed a C-secion for this, but she's got a great baby. No good deed goes unpunished.)

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