Month: March 2017

Categories
Clinical Lifestyle Public Health

What’s the Deal with Vaginal Breech Delivery?

Back in May, I attended the 2016 American College of Obstetrics and Gynecology (ACOG) Annual Scientific and Clinical Meeting in Washington, D.C. On my first day, I watched Dr. Annette E. Fineberg, a board certified obstetrician and gynecologist from Sutter Davis Hospital in California, present a short film on upright vaginal breech delivery. The movie featured a woman at term deliver in the operating room by resting on all fours on her hands and knees. She swayed her bottom from side to side in order to promote fetal descent and as a way to cope with pain, as she did not receive an epidural. The baby crowned, bottom first, and then slowly spontaneously delivered its legs, trunk, arms, and finally, head. A successful vaginal breech delivery (VBD)!

Ever since watching that amazing film, I have been interested in reading and talking about VBDs. But on the residency program interview trail, I have begun to notice a trend that some providers seem to have strong, negative attitudes regarding VBDs of singletons. One person even glared and incredulously responded, “No one in the country does those.” I think Dr. Fineberg and the other clinicians I have met that do would disagree.

But I do wonder why providers feel so strongly about a particular position regarding more controversial topics in reproductive health. In regards to vaginal breech delivery, I think that a big prejudice is the absolute horror stories every seasoned OB/GYN has to tell about the time they saw a baby’s head get stuck. These accounts are upsetting, sad, and help explain why someone might think me ridiculous for even asking about training in vaginal breech delivery.

The most common response, though, that I receive is something like, “We don’t do those. But you will probably not find many programs that do since ACOG does not recommend vaginal breech deliveries.” This reply is less emphatic and more accurate if following the 2001 ACOG committee opinion, which states, “planned vaginal delivery of a term singleton breech [is] no longer appropriate.”1 The reasoning in 2001 was largely based on results from the Term Breech Trial, a large, multi-institution, randomized control trial comparing planned vaginal birth with cesarean deliveries for term singletons with breech presentation. This study indicated that neonatal morbidity and mortality significantly increased with vaginal breech versus cesarean section delivery.2

Since the 2000 Term Breech Trial, clinicians have begun to question if vaginal breech deliveries should have a strict ban. Instead, there is evidence suggesting that vaginal delivery is a safe option in select women with breech presentation. The authors of the Term Breech Trial performed two prospective studies in which they examined maternal and child outcomes at both 3 months and 2 years post-partum. At two years post-partum, there was no longer a difference in mortality nor neurodevelopmental delay in the children born by vaginal breech delivery versus cesarean section.3 Retrospective studies with specific protocols similar to those described in the Term Breech Trial have shown excellent neonatal outcomes for vaginal breech delivery of term singletons.4-6 In 2015, Berhan and Haileamlak published a meta-analysis of 27 articles with a total population of 258,953 women comparing the morbidity and mortality of term singleton breech mode of delivery between 1993 and 2014. While the relative risk of perinatal mortality and morbidity was 2-5 times higher in planned vaginal delivery versus cesarean, the absolute risks of several variables, including perinatal mortality (0.3%) and fetal neurologic morbidity (0.7%), were low.7

In the updated committee opinion on vaginal breech delivery published in 2006 and reaffirmed in 2016, ACOG states that “planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.”8 The Royal College of Obstetricians, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada report similar recommendations.9-11 According to the ideal candidate for a term, singleton vaginal breech delivery is the following:12-14

  • Frank or complete breech presentation with flexed or neutral head attitude;
  • Estimated fetal weight between 2500 and 4000 grams;
  • A patient willing and comfortable with a trial of labor;
  • Clinically adequate maternal pelvis.

Contraindications to vaginal breech delivery are categorized as a fetal, maternal, or provider factor:12-14

Fetal Factors

  • Incomplete breech;
  • Hyperextended neck;
  • Cord presentation;
  • Fetal growth restriction or macrosomia;
  • Congenital anomaly incompatible with vaginal delivery (e.g. thyroid mass).

Maternal Factors

  • Patient unwilling to attempt/uncomfortable with a trial of labor;
  • Clinically inadequate maternal pelvis;

Provider Factors

  • Lack of operator experience.

Obstetrics governing bodies agree that external cephalic version—whereby a provider uses their hands on the abdomen to rotate the fetus in utero from breech to vertex presentation—should be recommended and attempted first before considering vaginal breech delivery. And all leading sources recommend that an experienced provider needs to be leading the delivery.

But if there are few opportunities in residency to practice vaginal breech delivery, how will there BE any future providers who qualify as experienced?

First and foremost, I hope to enter a residency program that provides me with the training I need to be a competent women’s health provider. But I also intend to seek training in vaginal breech deliveries, whether it is via simulations—which RCOG notes is an appropriate way to build experience 9—or via an elective at another institution where there may be further opportunities. My goal is twofold: (1) offer the best individual options for mode of delivery to my future patients; and (2) help lower cesarean section rates in the United States. Hopefully, I will get the right match!

References

  1. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.340: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2006 Jul;108(1):235-7.
  2. Hannah ME, Hannah WJ, Hodnett ED, Saigal S, and Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet. 2000;356(9239):1375-1383.
  3. Whyte H, Hanna 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;191:864-871.
  4. Guiliani A, Scholl 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;187:1694-8.
  5. Alarab M, Regan C, O’Connel MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407-12.
  6. Borbolla Foster A, Bagust A, Bisits A, Holland M, Welse A. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Autralian and New Zeland Journal of Obstetrics and Gynaecology. 2014;54:333-339
  7. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: A meta-analysis including observational studies. BJOG 2015: DOI; 10.1111/1471-0528.13524
  8. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.265: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2001 Dec;98(6):1189-90.
  9. Guideline No 20b: The Management of Breech Presentation. Oxford: RCOG, 2006.
  10. Kotaska AK, Menticoglou S, Gagnon R. SOGC Clinical Practice Guideline No. 226: Vaginal Delivery of Breech Presentation. JOGC. June 2009.
  11. RANZCOG, Cobs-11: Management of the Term Breech Presentation. Melbourne: RANZCOG, 2009.
  12. Hofmeyr JG, Lockwood CJ, Barss VA. Overview of issues related to breech presentation. UpToDate: Accessed 10/11/2016
  13. Hofmeyr JG, Lockwood CJ, Barss VA. Delivery of the fetus in breech presentation. UpToDate: Accessed 10/11/2016
  14. Secter MB, Simpson AN, Gurau D, et al. Learning from Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breach Deliveries. JOGC 2015

Photo credit: MIKI Yoshihito

 

 

Categories
Clinical Narrative Reflection

Red Rash

As I sat in the audience, I stared up at the image being presented on the screen. It was what looked to be another red rash. The content for the Dermatology grand rounds was admittedly beyond my clinical training. Nevertheless, I found it fascinating to slowly discover the complexities of the skin as each case was presented. As I thought about each slide I began to ponder Dermatology as a specialty. I wondered what it meant to be a dermatologist. I briefly reflected on the stereotypes associated with the profession and then realized that every specialty had stereotypes. My brief daydream was interrupted as the next image on the screen appeared. I was anxious to see what it was in hopes that I could identify it, but to my dismay it looked like just another red rash.

Later, as I scurried behind the attending in my official looking, yet noticeably shorter white coat, I wondered what type of red rash I would be observing next. As I entered the exam room the woman sitting there immediately shocked me. Her face read of complete sorrow and hopelessness. However, it was not her face that struck me, it was her skin. It was red, dry, and seemed to be peeling off of her as if she was shedding her skin. It looked terrible and seemed to feel even worse. It was then that I saw the attending spring to life. He began discussing her symptoms with her. When he had gathered the information he needed she began to tell him how the illness has been affecting her life. Skin diseases or issues with the skin can sometimes be viewed or reduced to something inconsequential or unimportant compared to other serious diseases such as diabetes, heart disease, or cancer. However, as I looked at this woman, I imagined her waking up in the morning and standing in front of the mirror and being unable to focus on anything other then this rash covering her entire body. It was then that she described the shame, embarrassment, and humiliation she experienced when others would stare at her, whisper about her, or when she would occasionally catch a glimpse of herself in a store window. The thought of her disease staring at her in the face when she brushed her teeth each morning made other serious illnesses that hide under the skin seem preferable.

After listening to her describe her quality of life it made complete sense as to why she felt so hopeless. It was in the moment that I had a strong desire to help this woman. I wanted to relieve her of this suffering. Fortunately, the attending was already in action. He began to describe his treatment plan while validating every one of her feelings and concerns. It was as if he knew what it was like for her to lose sight of herself and only see her skin. As the sorrow slowly drained from her face, I saw something incredible, hope.

It was then I realized that every slide I causally coined as a “red rash” belonged to actual people who have lives, families, and most importantly feelings. I assigned them a label that they never asked for and most likely hide from everyone they encounter. Assessing and treating the human body is an immense responsibility, but so is connecting with people. Now when I see the images at grand rounds I no longer see a red rash. I see a person who with the proper treatment and compassion can become whole again.

 

Photo credits:

Featured– Jean-Pierre Dalbéra

In-text- Taylor Thomas

Categories
Clinical Emotion Empathy Narrative Reflection

Takotsubo

Valentine’s Day is not typically kind to medical students. While many couples share flowers and romantic dinners, my fiancé and I looked forward to escaping the hospital just long enough to exchange sweet-nothings over take-out sandwiches. Though lacking in outward displays of affection, this Valentine’s Day was imbued with something different. A few weeks ago, a patient taught me that love, it turns out, can exalt us and confound us, but it can also, literally, break our hearts.

He was a thin man in his late seventies, a mop of unruly gray hair on his head. He came into the emergency room one evening, unable to catch his breath and complaining of severe chest pain. An EKG was rapidly obtained and showed concerning peaks and valleys of electrical activity. Troponin levels were rapidly increasing in his blood. TC, it appeared, was having a heart attack.

Image courtesy of Med Chaos

Though still in the early stages of my medical training, I knew what would come next. In rapid succession, TC would be rushed to the cardiac catheterization lab, and a stent would be placed in his coronary arteries, restoring desperately needed blood flow to his heart. He would recover. His loving wife and adult children would visit him in the hospital. In a few days he would return home.

I was wrong. Try as they might, TC’s doctors were unable to find any blocked arteries in his heart. With nothing to stent open, TC was admitted to the medicine ward for careful observation. Miraculously, his condition stabilized.

The next morning he was feeling better. Not wanting to forego his calisthenics, I found him walking along the bustling hospital corridor, pausing briefly outside each room to greet his fellow patients. As I corralled him back to his room for morning rounds, I couldn’t help but notice the gold wedding ring hanging from a length of frayed twine around his neck. He caught my gaze and smiled, “pretty, isn’t it?”

Lowering himself carefully to his bed, he explained why he no longer wore the ring on his finger. His wife, he lingered on the word, had died almost three months ago. His children, long since grown, had come home for a while, but were now back to their own lives. He’d considered moving into a smaller place—less lonely he figured—but he couldn’t bear the thought of discarding any of her things.

Later that day, TC went for an echocardiogram which immediately revealed his diagnosis.

He had Takotsubo cardiomyopathy, also known as “broken heart syndrome.” It is a rare condition, but strikes most commonly after a period of great emotional turmoil. Marked by chest pain and shortness of breath, the initial presentation is not at all dissimilar to a heart attack, so committed in its mimicry that the EKG and blood findings are often identical.

Although the pathogenesis of Takotsubo cardiomyopathy is not completely understood, it is postulated that adrenaline, released in times of great emotional distress, may overwhelm and eventually damage the heart. With enough damage, the heart breaks, contorting itself into a characteristic shape—wide at the bottom with a distinctively narrow neck. The shape resembles a Japanese takotsubo pot, a vessel historically used to trap octopus.

As a trainee in the field of medicine, my classroom preparation taught me to be objective—to plumb the pertinent facts of a patient’s history and physical exam in order to provide effective treatment. But it is patients like TC who teach me that good doctoring requires something more. Though less tangible, it is clear that one’s physical and emotional well-being are inextricably linked.

Several days later, heart ostensibly healed, TC was ready to return home. He stepped into the elevator, turned, and waved goodbye. A gold ring shone brightly on his finger.

Photo credit: Chandrahadi Junarto