A Current Commentary on Breech Vaginal Deliveries: The Changing Landscape of Patient versus Physician Autonomy
29 December 2018
08 February 2019
14 June 2019 (online)
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?
The author has no financial support and no conflicts of interest to disclose.
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