Breech (Buttocks First) Presentation Correction
In the few weeks before 36 weeks, be sure your baby is head down, after that time it is unlikely to turn on its own. In the weeks before this, you can perform breech exercises to help your baby turn. This is a simple position that involves getting on all fours with your buttocks in the air to help get the presenting fetal part out of your pelvis and allow your baby to turn naturally. 15 minutes a day is all the time required.
At 36 weeks, your physician should offer to perform an External Cephalic Version (ECV). This is a simple procedure where your physician meets you in Labor & Delivery places an IV, administers medication to relax your uterus then gently rotates the baby using some ultrasound gel placed on your belly. Some babies will summersault forward, some go backwards but in the appropriate patients, a good OB/GYN should have a 50-80% success rate. Please note that not all OB/GYN’s are comfortable performing the procedure and will just tell you that you need a C/S. This is just not true ECV, is a widely accepted practice supported by the American College of Obstetrics & Gynecology.
Excerpt from ACOG Practice Bulletin #13:
“Because the risk of an adverse event occurring as a result of ECV is small and the cesarean delivery rate is significantly lower among women who have undergone successful version, all women near term with breech presentations should be offered a version attempt…
- Patients should have completed 36 weeks of gestation before attempting ECV.
- Previous cesarean delivery is not associated with a lower rate of success; however, the magnitude of the risk of uterine rupture is not known.
- There is insufficient evidence to recommend routine tocolysis for ECV attempts for all patients, but it may particularly benefit nulliparous patients.
- Evidence is inconsistent regarding the benefits of anesthesia use during ECV attempts.
- Cost-effectiveness depends upon utilization of vaginal breech deliveries and costs of the version protocol at a particular institution, but at least one decision analysis suggests the policy is cost effective…
- Fetal assessment before and after the procedure is recommended.
- External cephalic version should be attempted only in settings in which cesarean delivery services are readily available.”
Twins, Does NOT Mean Automatic C/S
For some obstetricians, twins means C/S and they will tell you all kinds of reasons why. In short, if the first baby is head down you have a very good chance of delivering vaginally. The second baby if breech can be turned in the uterus after the first one is delivered, or if the doctor has been trained in breech vaginal deliveries, the second baby can be delivered in the breech position.
The Elective Induction, Buyer Beware
This has to be the biggest reason for the rise in C/S rate in the United States, likely only second to your doctor’s fear of being sued despite trying to do the best thing for you and your family. Elective induction can be convenient for both the mom and the doctor but buyer beware. If your cervix is not ripe (dilated and thinned out) prior to an attempted induction of labor you have up to a 90% failure rate for your induction which usually translates to you getting a C/S. Now, if you are dilated to 3 cm at 39 weeks and want to have your baby by the afternoon then go for it! I have no problem with electively inducing you because the success rate is high.
However, if your cervix is closed just wait. I will wait up to 41.5 weeks before some intervention is required. After this point, studies show your baby can have a poor outcome. Of course, we monitor you in the office after 40 weeks to make sure your amniotic fluid level is normal and the baby’s heart rate is reassuring. While we wait, most patients go into labor spontaneously or dilate enough to allow for successful induction and vaginal delivery.
The Cesarean Myth
The Vaginal Birth After A Cesarean Section or VBAC* does exist. You just need to know the criteria and the risks. Of course, you have to find a doctor willing to stay with you during your labor in case a C/S is needed. Unfortunately, the VBAC is becoming less frequent as a result. I have had very good success with VBAC’s the key is to follow the rules. This is an article in itself. Needless to say, one of the keys to a successful VBAC is patience. The mom has to go into labor on her own and cannot receive any medication to induce or augment labor. I discuss all this with you at your initial visit and then you and your significant other get to go home and discuss it. In addition, you can change your mind at anytime and say Dr. Weinstein I just want a C/S and I say, “no problem.”
*Dr. Weinstein no longer taking new VBAC patients.
It amazes me how many people are still getting a C/S because they have a herpes outbreak when they go into labor. There is a simple blood test to see if you have ever been exposed to the virus most commonly associated with genital herpes. On a regular basis I see OB patients in monogamous relationships with no history of Herpes come back positive for prior exposure. In fact, 1 in 5 adults, more women than men, or 45 million people have Herpes. You might not know the symptoms or maybe you have outbreaks that are in your vagina or you are just asymptomatic. Maybe you got it three partners ago and have been married for five years. Men do not have outbreaks as often or bad as women. My point is there is a single pill that can be taken daily from 36 weeks on that almost always prevents you from having an outbreak when you deliver.
When you are pregnant your immune system is suppressed so your likelihood of an outbreak is higher, which by the way is the same reason your cold lasts twice as long as everyone else’s when you are pregnant. So please ask your doctor to test you. Herpes exposure to a newborn can be life threatening. A blood test and a simple pill can prevent a C/S and ensure a healthy baby
As you can tell, I am a big fan of the vaginal delivery. I have seen what multiple cesarean sections can do to a women’s anatomy, it triples your blood loss compared to a vaginal delivery, results in emergency hysterectomies because the placenta of this pregnancy decided to grow over your last scar so it won’t detach, among countless other unpleasant things. Now some people just need a C/S whether it be for fetal distress, failed ECV, medical reasons, the baby is too big to fit through your pelvis etc. Moreover, if this is the case, in an emergency a good OB can deliver a baby by C/S in 1 minute from skin to birth.
I would not suggest or agree to anything that I did not feel comfortable with for my own family. This applies to everything I do as a women’s health physician and in life. Whether it is gynecology in the office, surgery at the hospital, treatment of a cold or urinary tract infection, recommendations for preventive care, counseling on depression, anxiety or smoking cessation or delivering your beautiful child. I want you to feel comfortable speaking with me, I want to hear about your family and I want you to be healthy and happy.
Thanks for your time.
Jonathan R. Weinstein, MD, FACOG