A Current Commentary on Breech Vaginal Deliveries: The Changing Landscape of Patient versus Physician Autonomy

Clinical Case

A 38-year old G2P1001 presented for a second opinion at 34 weeks of gestational age. Her obstetric history included a term vaginal delivery of a 3,460 g infant complicated by a postpartum hemorrhage requiring the administration of oxytocin, methergine, hemabate, misoprostol, and curettage for resolution. Her current pregnancy was a spontaneous dichorionic diamniotic twin pregnancy. The fetuses were concordantly grown and the pregnancy had otherwise been uncomplicated. She sought a new obstetrician as her physician had recommended a cesarean for breech/breech presentation and declined to offer a vaginal delivery in this circumstance.

The risks and benefits of a primary cesarean delivery, an attempted version of the first twin, and an attempt at breech/breech vaginal delivery were discussed. Potential complications were discussed with the patient to include cord prolapse, fetal distress, head entrapment, fetal death, and neonatal developmental delay. The potential need for Dührssen's incisions, forcep delivery of the aftercoming fetal head and the unlikely event of twin locking should the second fetus become cephalic were discussed. The American College of Obstetricians and Gynecologists (ACOG) guidelines recommending cesarean in her situation were reviewed, as was the paucity of trial data regarding breech/breech twin deliveries. The provider's experience with breech vaginal delivery was discussed with the patient. She was given an approximate 30% risk of requiring emergency cesarean delivery. The patient was advised that the provider thought her chance of requiring forceps for the delivery of one or both twins was likely also approximately 30% and informed that these estimates were based on the provider's experience with the proposed procedure. The patient decided to pursue vaginal delivery.

The patient developed severe cholestasis of pregnancy with her total bile acids returning at a value of 96 umol/L at 36 ^5/7 weeks of gestation. Delivery was recommended. The fetuses were in complete breech (Twin A) and transverse (Twin B) presentations. She chose an induction of labor. Her starting Bishop score was 8. An oxytocin infusion was commenced. During a cervical examination at 6 cm dilatation, 70% effacement, and −1 station, the patient's membranes ruptured with confirmation of fetus A in a complete breech presentation with the right fetal foot, the fetal genitalia and the sacrum presenting. No umbilical cord was palpable. Epidural anesthesia was administered. The patient progressed over the next several hours to complete dilatation and was allowed to “labor down” for approximately 45 minutes at which time she was transferred to the operating room for delivery. She delivered Twin A, a complete breech fetus, without the need for assistance with forceps. Newborn was a 3,090 g male with Apgar scores of 7 and 8. A breech extraction, in combination with maternal expulsive efforts, was performed of twin B which presented as a frank breech. Again forceps were not required. The newborn was a 2,750 g female with Apgar scores of 9 and 9. In spite of active management of the third stage, the uterus did not readily contract. At placental separation the patient began bleeding and uterine atony was diagnosed. At 5 minutes after placental delivery, the provider estimated blood loss to be at least 1,000 mL. The atony was refractory to oxytocin bolus, hemabate, methergine, misoprostol, tranexamic acid, and continued bimanual massage. The anesthesiologist called to have blood products available and a second obstetrician was made aware that a postpartum hemorrhage had been diagnosed. A Bakri balloon was placed and inflated to 500 mL. The estimated blood loss was 1,300 mL at this time and bleeding resolved. Laboratory testing was performed and a stable maternal fibrinogen was noted at 861 mg/dL. The total hemoglobin drop over serial laboratory examinations over 6 hours was 5 (from 15.4 to 10 g/dL). The Bakri was removed the following morning without recurrence of bleeding. Both babies and mother were clinically stable and were discharged from the hospital on day 2 after delivery.

This case highlights a quandary: a patient makes a request for vaginal delivery and seeks a provider willing to support her in her decision. The immediate question is whether this is a reasonable request (is practice outside of guidelines in this case acceptable)? Secondarily, which party's autonomy should be paramount in this situation, the physician's or the patient's?

Disclosure

The author has no financial support and no conflicts of interest to disclose.

• References

• 1 Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. ; Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356 (9239): 1375-1383
• 2 Kotaska A. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ 2004; 329 (7473): 1039-1042
• 3 Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants. BJOG 2005; 112 (02) 205-209
• 4 Hannah ME, Whyte H, Hannah WJ. , et al; Term Breech Trial Collaborative Group. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191 (03) 917-927
• 5 Whyte H, Hannah ME, Saigal S. , et al; Term Breech Trial Collaborative Group. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191 (03) 864-871
• 6 Giuliani A, Schöll WM, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol 2002; 187 (06) 1694-1698
• 7 Alarab M, Regan C, O'Connell MP, Keane DP, O'Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004; 103 (03) 407-412
• 8 ACOG. Mode of term singleton breech delivery. ACOG committee opinion. Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Mode-of-Term-Singleton-Breech-Delivery . Accessed February 22, 2019
• 9 ACOG Committee on Practice Bulletins--Obstetrics. Practice bulletin no. 161: external cephalic version. Obstet Gynecol 2016; 127 (02) e54-e61
• 10 ACOG. The limits of conscientious refusal in reproductive medicine. ACOG committee opinion No. 385. Obstet Gynecol 2007; (110) e1203-e1208
• 11 Azria E, Le Meaux JP, Khoshnood B, Alexander S, Subtil D, Goffinet F. ; PREMODA Study Group. Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery. Am J Obstet Gynecol 2012; 207 (04) 285.e1-285.e9
• 12 Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002; 187 (04) 824-828
• 13 Zhang J, Troendle J, Reddy UM. , et al; Consortium on Safe Labor. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 2010; 203 (04) 326.e1-326.e10
• 14 Committee on Practice Bulletins—Obstetrics; Society for Maternal–Fetal Medicine. Practice bulletin no. 169. Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies. Obstet Gynecol 2016; 128 (04) e131-e146
• 15 ACOG Committee on Ethics. Committee opinion no. 664: refusal of medically recommended treatment during pregnancy. Obstet Gynecol 2016; 127 (06) e175-e182
• 16 Arizona Department of State. Chapter 16. Department of health services–occupational licensing. 2017 September 2018; Available from: https://apps.azsos.gov/public_services/Title_09/9-16.pdf . Accessed February 22, 2019
• 17 ACOG Committee on Obstetric Practice. Committee opinion no. 697: Planned home birth. Obstet Gynecol 2017; 129 (04) e117-e122
• 18 Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010; 203 (03) 243.e1-243.e8
• 19 Woman, 36, who campaigned for home births dies having baby daughter at home. 2012 ; Available from: https://www.dailymail.co.uk/health/article-2094348/Caroline-Lovell-Home-birth-advocate-dies-delivering-baby-daughter-home.html . Accessed February 22, 2019
• 20 ACOG committee opinion no. 559: Cesarean delivery on maternal request. Obstet Gynecol 2013; 121 (04) 904-907
• 21 ACOG Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol 2012; 120 (01) 207-211
• 22 Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Bréart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 2006; 108 (3, Pt 1): 541-548
• 23 ACOG committee opinion no. 390, December 2007. Ethical decision making in obstetrics and gynecology. Obstet Gynecol 2007; 110 (06) 1479-1487